OF

Repu blic of the Philippines

BICOL UNIVERSITY
llt( Ol- (r\lvi:lls11-\'lllrAl.'l H SER! l( Ut
Legazpi City
(052 ) 480-0462

REOUIREMENTS FOR PHYSICAL/DENTAL EXAMINATION ON ADMISSION

Dear Stude nt,

Congratulations and Welcome to Bicol Universityl

It is our mission to provide and to promote the maximum health assistance

in maintaining the welfare of the students while in the University.

In this regard, may we request you to fill up the attached Student's Health
Record Form & Indivldual Dental Health Record and report to Bicol University
Main Clinic (BUCE Campus) for your fvledical and Dental Examination on
at _:00 a.m./p.m.

Please brino the followino:

1. Bicol University College Entrance Test (BUCET) Result

2. Student Health Record Form/Individual Dental Health Record
(Please accomplish before reporting on yaur scheduled date and
parent/gudrdian must sign the form)
3, Chest X-ray Film and Result,
4. Ordinary Long Brown Envelope & Blue Ballpen
5. Hepatitis B Test Result IFor Nursing, BSIE (Mj. in Food Service Mgt.) ;
BSFT; BS Entrep., Fisheries & Medicinel

Strict compliance to the schedule is hereby requested

Very truly yours,

(-
DR, JULIO M, ABAINZA
Medica I Officer
N oted
I
,\
DR. HELEN M, LLENARESAS
vp for Acaderi{ic Affairs/ Head UHS
/
I

8U.F.UHS 04
l, 2crl7 Page 1 ol I
Etfectivity D.rte: O€tober l
 Republic of the Philippines
BICOL UNIVERSITY
BICOL UNIVERSI'I'Y HEAITH SERVICES
Legazpi Clty
@ p
Tel. #: (052) 480-0462

,}rfDICAL PATIfNT AECOPD

COU RSE,/G RADT/Y EAR:

UNlll -

Name: Birthday:
Month / Oote / Yeor
Address Religion:
NO, Sa/eet Mun)cipolity/Aty
Contact Number(s) Clvll Status Sex __ Ate:
-.--
Parehtsi office Addrert Contect No.
Fathe/s Name
Molhe/s Name

ln aase o, EmerEency plea5e notify

Contact Nr

lllness:
D Hypenenslon f] a.,r,n" I mu.p,
D Diabete5 f] nheumattc feve, D cardlac Diseare

C Kldney Dlseare ! sekure dtsorder ! clrr"n po,

D Mearles Dxepatttis D Tubercutosir
D Dlphtherla f--l Allerst ueose,na,mr.t
Oahe.s (specfy): _

I
EXAMINAT'OlVS
--' Tom pe.at ure'/
]D ate Blood Weight Height History and Phyclcal Exarninatlon Phy!lqian's Djrectlon.
Pressure

l _l
--ll

D6 No. EU-F-|-,HS{A
En&n vhy Oarer Odob€. 1 1 . 201 7
 EXAMINAT'OIVS t.
I

Temperatur€r'
Date Blood Welght Hoight Hirtory and Physical Examinatlon Phyglclan's oirectionB I

Prea6ure

I ,]

_l

Ooc No : BL!F-UHS'06
Eli..irv y D.rB clctoDor11,2017
 ) 6-.
Republic of the Philippines
BICOL UNIVERSITY
BICOL UN IVERSITY HEAL'I'H S!]RVICES
Legazpi City
Tel. #: (052) 480{462

TO WHOM IT MAY CONCERN:

This is to certi:y that , _years old,
female/male, single/married of
was examined/treated in this clinic on

Findings: Pb/ticalb/ fa

Recommendation:
Pb/tica 4/ fLt tc>earol /, for ftezhme,ru

lss ued and valid up to for reference

purpose only.

DR.JULIO M. ABAINZA
Medicai Officer

a
tr I
au-f.UHs-01
Effectrvly Oare: Oclob€r r1.2017

) I I
6n
r
\
Republic of the Philippines
BICOL UNIVERSITY
BICOI- U\ IVERSITY HEA LTI I S IRY ICES
Legazpi C ity
Tel. #r (052)480-0462

TO WHOM IT MAY CONCERN: Doc. No.: BU-F-Clinlc-01

This is to certify that , Years old,

female/male, single/married of
was examined/treated in this clinic on

Findangs:

Recommendation:

lss u ed for rete rence purpose onlY

DF. JULIO M. ABA1NZA

Medical Officer

eI
Eflectivity Oate: October 11, 2 017
 BICOL UNIVI'RSI'r'Y Btcol.UNtvtaRSl fY
@?
Health Services Health Services
LogazpiCity Loga:piCity
480{462 480-0462

MEI)ICAL TRESCI{IP'TION MEDICAL PRESCITIP'I'ION

Name of Patient
Address Name of Patienl _
Sex
Addrcss _Age _ Ser

Date
Date -
(

& l}

DR. JULIO M. ABAINZA M D DR. JULIO M. ABAINZA M D

Lrc No. I 62918 Lrc No 62918
PTR No.. PTR No
S, Ne
52 Ne

ooc No 8u-F-UHS-r3
Enecnvty Ost€ &robe, 11. 2017 Ooc No 8U-F-t BS,1!
E(ectrvrry Dal€ Ocrobe. 1r 2017
 @

BlcoLLuN:,u"f,""t*
C RADE/SECTION
S CBOOL YEAR,-.-"
CAM P!5

HEALTH RECORD
INDIVIDUAL DENTAL
AGE

PIlDOL EN AI.IE
FTRST
E DATE OF BIRTH:
N9.r
E: CEL LPHONE
N At',I SURT{ AI,4E TEL E9HO NE/ oc CUPATI ON:STU DENT:
SEX:
ADD RESS: RE TATIO N TO
cwl L S'TAT US:
NAM EOFPA
REN llGulno IAN:
CONT ACT N9;

co N Cl'-10N
63 64 65
OPERATION
5: 51 62 LEFf
55 5,r

RIGHT LEGEND,
SOUNO TOOT}I
V . CARIES FREE
coNDlnoN
OPERATION
26
!i 3f[1';''.*"-''n
24 25
15 14 l3 12 !l 2)
34 35 36 3' 38 AB- ABCESS
18 \'7 !6 4Z 3 3 33
U9PER 43
LOWER ll-11?l,l'HXI|'i'''
c - GrNGlvlnS
ir. rrupoplnv rtLltlc
ptlt-ttlc
coN olT:oN p - penHlnErur
OPERATION
M - I.1I SSING/UN ERUPTED
tEFT AS. ABUTMENT
RIGHT ]C. IACKET CROWN
s84B3 82 8l 7t 72 73 74 75 PG. PRESCRIPTION GIVEN
X - INDICATEO FOR
CONOITION EXIRACflON
OPERAl':ON
XM. EXTRACTEO
(LABIO BU CAL)

DAfE OF EXAMINATION
-+--- _'-r'
AGE AT I.AST B]RTHDAY
I

PaasENcE oF oENTAL cARIES YN YN N N N YN YN

PRSSENCE OF GINGIVTTIS N YNYN NY N YN
NIY N,Y
PRESENCE OF PERIODONTAL POCKET
PRESENCE OF ORAL DEBRIS
PRESENCE OF CALCULUS
N
N

N
N-

N
1--Y
N

i\]
t+ N-T
N
Y N

N
YN
YN YN
N

PRESENCE OF NEOPLASM N \ N YN]YN \

PRESENCE OF DENTO.FACIAL ANOMALY N N N NIY N Y N Nl
T n T T PIT T T ;P'
,I NUMEER OF TEETH PRESENT
;
o CARIES ]NDICATED FOR FILLING
o
f CARIES INDICATED FOR EXTRAC]']O
1l
ROOT F&AGMENT
a
MISSING DUE TO CARIES
FILLED OR RESTORED I
_-l
T TOTAL OF AND DMF TEETH --t- I

FLUORiDE APPLICAT1ON
EXAMIN ER RH LtI LN RM L[I rN-r RH I LN J Rfi LN i RNr
-LN
Ooc Ns AU'F-UH5-2!
Efiectrvrty D.re Oclob.r I l. 2017
I- PATIENT'S HISTORY: (To be fi ed by the parienr/student)

1. OPERATION (In any part of the body) yES ! NO D

If yes, specify (ex. Appendectomy)
2. Any allergy to food or medication? yES NO o
If with allergy, specify (ex. To s hrimp, penicil rn , etc. )
3 Biood Diseases?
If yes, specrn, (ex. Anemrc)
YES C No A
4. Fainted? YES NO If yes, Cause
D
5 Do you haYe attacks of Asthma? YES ! NO ! with History _ Date of Last Attack
6. Do you have Heart Ailment? YES ! NO C If yes, !Vhat?
7. With Hepatitis? YES o NO o If yes, what?
8. Positive of Pulmonary Tuberculosis? YES
D NO
!
Radiographic lnterpretation
9. Suffering of Frequent Headache? YES ! NO ! If yes, *hy?
1l - BLOOD PRESSURE: __mm H9

III - TREATMENTS:

DATE TREATI,IENT TOOTH N9 DENT]ST REI.4ARKS

2A Dr. Monaste(o / Or. Nuyles
20 Dr. l,lonasteno / Dr. Nuyles
2A Dr. Monasteno / Or, Nuyles
20 Dr, Monaste(o / Dr. Nuyles
20 Dr. Monasterio / Dr, Nuyles
I /20 Or. Monasterio / Or. Nuyles
20 Or, Monasterio / Dr. Nuyles
/ /20 Or. Monasterro / Dr. Nuyles
i /24 Dr, Monastero / Dr. Nuyles
I /20 Dr. Monrsterio / Dr. Nuyles

/
20
/24
/20
Dr.
Dr.
Dr.
Monaste(o
Monastero
Monasteno
/
/
/
Or.
Dr.
Dr.
Nuyles
Nuyles
N{ryles
I
/ /20 Dr. Monasteno / Dr. Nuyles
/ /20 Dr. /
l"lonast€rio Dr. Nuyles
2A Dr, Monasaeno / Dr. Nuyles
2A Dr, Monasterio / Dr. Nuyles
20 Dr. Monasteflo / Or. Nuyles
/ 120 Dr. Monasteno / Dr. Nuyles
t2A Dr. Monasteno / Or. Nuyles
20 Tor.r"rona sEi,o I 0r. Nuyles i
20 Or. Plonasierio / Dr. Nuyles
20 Dr. Monasterio / 0r. Nuyles
2C r Dr. Monasteflo / 0r. Nuyles
2A Or. l4onasteio / Dr. Nuyies
20 Dr. I{onasterio / 0r. Nuyles
20 Dr. Monasteflo / Dr. Nuyles
I l2A Or. Monasteno / Dr. Nuyles

IV - To be filled by the Oentist

Occlusion
Cl. I type
Cl. II Division _Subdivision __ ___ Type
Cl. III Division Subdivis'on
Blood Sugar: Normal __._, ..._ B gh Low _ ___.,-_ ._ _
Bleeding Tlme (value),. . _
Clotting Time (value) _.-
Remarks I

Doc Ne r 8U-F-UHS-21
Effectr!ity Dere 0ctober 11,2017 RPv No 0 Page 2 of 2
 I

6
FILE N9

BICOL UNIVERSITY -]]

BICOL UNlVERSITY HEALTH SERVICES
Legazpr City
COURSE/'/EAR

I,'IODLE NAUE
ADDRESS: DATE O- BIRTH:
CIVILSTATUS:5EX:--_IELEPHoNE/cELLPHoNEN9.:---
NAME OF PARENT/ G UARDIAN: OCCUPATION:
CONTACT N9; . RELATIOI{ TO STUDENT:
--
n I
LTGEND

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C]. OENTAL CARITS lVI IH
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cA- NEtD ORlriODOtJli(
;
I ponr tc

I PA-iiti,ii S lliSiCRY: (To ac fiiied by the patient/'stud6rnt) PII,ASICHECTi

.r. t,rEr(Arrur! irr dry pdrL ur Lrrs uuuy./. L _l tE) j.- I

:r r,... ..tx,. 't;. :-, i1,;,r,rrl-, li;,r';i.._ _ _
2. Any allergy to food or medication? n vES n NO

It with allergy. specify (ex. To shrirnp, penicillrn, etc.)

i oluuc ur>Ed::5: il ;,g5, *.,nU, :ex. An€qir(,
L____l

5. Do yoi, irave atta.ks ofAstirnia? NO rith histcr-,: Ddti' oF I .ist Ai:.tci

6. Do you have Heart Ailments? YES NO lf yes, What?
7. With HepatitisT YES NO If yes, What?
t. PuSrtive ul full,ru!]31] irlerauiOSIS? t.r l,lo i{Jdiogr,lpilrr- iriter IrreLdtrurl :

-
If yes, Why?
9. Suffering of Frequent Headaches? t.-r YE5
t_l NO

Do< N9 EU I Uf! ll
Eifectrvrly ()rlol)er ll 20i/
 DATE OF EX,/\MINATION I I
1

BI RTH DAY
I
PR'SENCE O DENTAL CARIES YN YN YN YN N YN YN
PRESENCE OT GINGIVITIS YN YN YN YN YN YN YN l
PRES ENCE PERIODONTAL POCKET YN YN YN YN YN YN YN
PRESENCE O ORAI DFBRIS YN YN YN
'Y
YN YN YN N

PRESENCE O CALCULUS YN YN .-Y N YN YN YN N

lnesrrucr o N EOPLASM YN YN N YN YN YN YN
PR€SENCE O DENTO-FACIAL ANOMALY YN YN YN YN Y YN YN 1

T T P T T T T P T P

NUMEER OT TEETH PRESENT o

I € I

o CARIES I DICATED FOR FILUNG c I

o
CARITS I DICATTO FOR EXTRACTION
ROOT GMENT
t
c
o MISSING DUE TO CARIES
FILLED OR RESTORED
-9,
M
X X X X X
T TOTAI. OF ANO DI.,IF TEETH
FLUORIDE APPUCATION
EXAMINER RM LN LN LN RM LN RM LN iN

lli TREATT'4ENTS:

DATE TREATMENT TOOTH N9 DENTIST REMARKS

/ /20 Check-up r Afl ( u/L) I

I 120 I

I /20 *
/20
/20
I /20 I

/ t20
/20 1#
'--l
/70 lr *J i

I /20
/ /20
/ /20
/ 120 I

I /20
/20 t
/20
/20
/ /20
.l
/ /20 I

/ /20 ll

lV - To be filled by the Dentist:

Occlusion
Cl. I type
Cl. Il Division
Cl. III Drvrsion =-Subdivision Type
Subdivision
Blood Sugar: N ormal High
Bleeding Time (value)
Clottrng Trme (value) __
Remarks:

Do.. N.: BU.r UHS-21

E6e.t,v,ry: Ortober I l, 2017
Page 2 of 2
 Repuhlic of the l'hilippine:
fe) r^r
BICOL UNIVERSITY
Bl{ .)t I \lt r:k\tL t t..tt tH \i.l<t l( t:\
Legazpi City
(052 ) 480-0462

.t7[rf .\'T t] E.1 t.7'It REC0Rt)

Coursel
(Please p nt wtn BLU€ Ealipen) Cam pu s

Name Age _ Se.x _

Las/ Fitst
:aie ol I t': nIlEIlII Home rosress

N AII E lvl,rti e r s flalne

Cccupalron Occupatron
af1,.a Ad.rE<< C_ff re AOdreSS
la a:--^r' :'.::
l.tame of Guardlan lri app|cablel
Address Tel Nc

Family H istorv (Please put an "r" rl yes orno and rn(icate rtlar:cnshrp il yes )
-_- your blood relalives iS lhere hrslory of any ol the fol owrng?
Arnong
YeS No Re Ial ron Yes No Relatroll
Cancer DD Diabetes L:] LJ
Heart disease
Hypenension :l -,
Mental Disorder
Asth m a
a:l D
-r- =I
D-
Stroke
Tuberculosrs
Kidney Problem
r:t D
Tt:]
Convulsion
BleedinO tendencies
Gastroinlestinal disease -n f:]
.::
Rheumatism i:r E Skin Problems
Eye Disorder tr ---)
PersonaI Histor v PIs Check (\) il yo! had the followinq symp!oms or rllness
PAST ILLNESSES (lt4ga Nagrng Sakil)
Primarycomplex E ,qsthma Ll Rheurnat,c Fe"er chicken pox
= --J
I Kidney Drsease .: Skrn Problems [j Drabetes :: Eye Disoroer
[= Pneumonia J fl Dengue Measles [] Poliomyelitis

C Ear Problems Mumps I Thyroid Disoroer --- l-iearl Disease

[J l\,4ental Disorder = Typhoid Fever -- Hepatfls [:] AnemralLeukemra

-
PRESENT ILLNESSES
Presenl Symptoms. (Mga sintomas na mararamcaman)

i----j Chesl Pain f:l Headaches ----l Nausea^/omiting

-
lnsomnia
irdrgestion Sore throal (Fr€quenrr Difficult Breathrng Joint Pains
Swollen Feet Dizziness -l
rJ Weight Loss Frequent Urination

Oo you have history of hospitalizalion for serious illness operalion, fracture or inlury?DYES a- NONE
lf yes, please give details

Aae you taking any medrcrne regularly? nYES J NO. lf yes name cl orugrs

. Are you allerglc to any food or medicrne? (ex Penrcrllrn aspi.in shiimp chicken. etc ) YES l--.l No
lf yes, specify =
lmmun ization History:
Polio Vacc.rne L ll lll Boosler Dcses Iy' um ps Typhoici
= = =
Chrcken Pox DPT I ll, lll, Booster Doses [/leasles D German measles

Hepatitis A Hepatllis B
Other lspecifyl

Sronarlrre of StLden! Sighal,rre ci Parenls lale S gneo

Oo<. No: BU-F'UFS_05

:tf€ctrv ry Da-ia oclober t1. 20r7
 Date:

COU R sE/
GRAD E TREATMENT
NAME SIGNATURE COMPLAINT/S DIAGNOSIS R EF E RRAL/REMARKS
Nq YEAR.I (ll ne.ded)
S EC TION
MEDICATION/S

Doc. Nq: BU+{linic-17 Revision:0

Effectivity dale'. August 2,2010 Page _
6)r.
,f)