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    Medical Record: Contact Person in Case of Emergency Name Imelda Andres Sales Relationship Mother CP# 09560970616

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    Solsona Natl HS Maananteng
    This document contains medical records for Lorenzo Dela Cruz, including his personal information, medical history, physical examination results, dental records, and a request for laboratory examinations. It provides his name, age, address, birthdate, and contact details. It documents his height, weight, blood pressure, and other vital signs from a physical examination. His dental records and a request for sputum exam or chest x-ray are also included.

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    Medical Record: Contact Person in Case of Emergency Name Imelda Andres Sales Relationship Mother CP# 09560970616

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    Solsona Natl HS Maananteng
    54 views3 pages
    This document contains medical records for Lorenzo Dela Cruz, including his personal information, medical history, physical examination results, dental records, and a request for laboratory examinations. It provides his name, age, address, birthdate, and contact details. It documents his height, weight, blood pressure, and other vital signs from a physical examination. His dental records and a request for sputum exam or chest x-ray are also included.

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    This document contains medical records for Lorenzo Dela Cruz, including his personal information, medical history, physical examination results, dental records, and a request for laboratory examinations. It provides his name, age, address, birthdate, and contact details. It documents his height, weight, blood pressure, and other vital signs from a physical examination. His dental records and a request for sputum exam or chest x-ray are also included.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    54 views3 pages

    Medical Record: Contact Person in Case of Emergency Name Imelda Andres Sales Relationship Mother CP# 09560970616

    Uploaded by

    Solsona Natl HS Maananteng
    This document contains medical records for Lorenzo Dela Cruz, including his personal information, medical history, physical examination results, dental records, and a request for laboratory examinations. It provides his name, age, address, birthdate, and contact details. It documents his height, weight, blood pressure, and other vital signs from a physical examination. His dental records and a request for sputum exam or chest x-ray are also included.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    MARIANO MARCOS STATE UNIVERSITY

    Document Code HWS-FRM-001


    Health & Wellness Services

    Revision No. 0 Page 1 of 1


    MEDICAL RECORD
    Effectivity Date September 1, 2019

    PERSONAL DATA
    SURNAME DELA CRUZ COLLEGE:

    FIRST NAME LORENZO COURSE:

    MIDDLE NAME DATE: 2021/08/25

    PERMANENT ADDRESS BGY. NO. 14, SANTO TOMAS (POB.), LAOAG CITY (CAPITAL), ILOCOS NORTE

    DATE OF BIRTH (mm/dd/yy) 09/27/94

    PLACE OF BIRTH Quezon City

    AGE 26 CITIZENSHIP Filipino

    SEX MALE ☑ FEMALE ☐ RELIGION


    CIVIL STATUS SINGLE ☑ MARRIED ☐ CP # 09092946235
    FATHER'S NAME ELMER GONGORA PERDIDO OCCUPATION FARMER
    MOTHER'S NAME Antonette Chantengco dela Cruz OCCUPATION
    Contact Person in Case of Emergency Name IMELDA ANDRES SALES Relationship MOTHER CP # 09560970616

    PERSONAL AND FAMILY HEALTH HISTORY

    (To be filled up by the MEDICAL STAFF)


    HAND USE IN WRITING LEFT ☐ RIGHT ☐ BMI
    HEIGHT (m.) RESP. RATE
    WEIGHT(kg.) CARDIAC RATE
    BLOOD TYPE BLOOD PRESSURE
    VISUAL ACUITY
    WITHOUT EYEGLASSES LEFT EYE 200 100 70 50 40 30 25 20 15 RIGHT EYE 200 100 70 50 40 30 25 20 15
    WITH EYEGLASSES GRADE: GRADE:
    MEDICAL HEALTH HISTORY
    A. IMMUNIZATION 1st DOSE 2nd DOSE 3rd DOSE 4th DOSE

    HEPATITIS B
    PHYSICAL EXAMINATION (to be filled up by the MEDICAL OFFICER)
    R E M A R K S
    SKIN ☐ Normal
    HEENT ☐ Normal
    CHEST AND LUNGS ☐ Normal
    HEART ☐ Normal
    ABDOMEN ☐ Normal
    GENITO-URINARY ☐ Normal
    EXTREMITIES ☐ Normal
    LABORATORY EXAMINATION RESULT
    DIAGNOSIS:

    RECOMMENDATION:

    SIGNATURE:
    _________________________________________
    _________________________________________
    PHYSICIAN
    STUDENT
    MARIANO MARCOS STATE UNIVERSITY
    Document Code HWS-FRM-010
    Health & Wellness Services

    Revision No. 0 Page 1 of 1


    DENTAL RECORD
    Effectivity Date September 1, 2019

    PERSONAL DATA
    SURNAME DELA CRUZ COLLEGE:

    FIRST NAME LORENZO COURSE:

    MIDDLE NAME DATE: 2021/08/25

    PERMANENT ADDRESS BGY. NO. 14, SANTO TOMAS (POB.), LAOAG CITY (CAPITAL), ILOCOS NORTE

    DATE OF BIRTH (mm/dd/yy) 09/27/94

    PLACE OF BIRTH Quezon City

    AGE 26 CITIZENSHIP Filipino

    SEX MALE ☑ FEMALE ☐ RELIGION


    CIVIL STATUS SINGLE ☑ MARRIED ☐ CP # 09092946235
    FATHER'S NAME ELMER GONGORA PERDIDO OCCUPATION FARMER
    MOTHER'S NAME Antonette Chantengco dela Cruz OCCUPATION
    Contact Person in Case of Emergency Name IMELDA ANDRES SALES Relationship MOTHER CP # 09560970616

    PERSONAL AND FAMILY HEALTH HISTORY

    (To be filled up by the DENTIST)

    REMARKS:
    DIAGNOSIS:
    RECOMMENDATION (FOR UNIVERSITY DENTIST ONLY)

    _________________________________________
    _________________________________________
    SIGNATURE OVER PRINTED NAME
    STUDENT SIGNATURE
    PRC NO.
    DENTIST
    MARIANO MARCOS STATE UNIVERSITY
    Health & Wellness Services

    CLINICAL LABORATORY REQUEST

    NAME: DELA CRUZ, LORENZO


    AGE: 26 SEX: MALE DATE OF BIRTH: 09/27/94
    LABORATORY EXAMINATIONS
    ☐ Sputum Exam
    NOTE: For pregnant and lactating women, cross out the chest x ray and kindly check mark the Sputum Exam.

    Note*

    (The degree programs under BS in Nursing (BSN),


    BS in Pharmacy (BSPH),
    BS in Physical Therapy (BSPT),
    BS in Food Technology (BSFT) of College of Agriculture, Food and Sustainable Development,
    BS in Tourism Management (BSTM),
    BS in Hotel Management (BSHM),
    BS in Industrial Technology - Food Processing and Service Mngt (BSIT-FPSM) and
    Bachelor of Technical-Vocational Teacher Education - FSMT (BTVTED - FSMT)
    is required to have complete HEPATITIS B VACCINATION (childhood immunization is considered).)

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