P.E. No.
:0000003106
Far Eastern University
Nicanor Reyes Medical Foundation
WORK INTERNSHIP/ RISK ASSESSMENT AND EVALUATION
Name: (Surname, Given Name, M.I.) Age Sex Civil Status Religion Nationality
VIZCARRA, ANA KRISTINA 19 FEMALE SINGLE ROMAN CATHOLIC FILIPINO
Address Contact No.
46 ROXAS STREET BUGALLON NORTE RAMON, ISABELA 3319 09399316044
School / Course Application No.
MEDICINE MD1900954
Check the appropriate box. Please fill in honestly and completely.
PAST MEDICAL HISTORY YES NO REMARKS
Do YOU have any history of:
Hypertension/ Highblood /
Diabetes /
Asthma /
Heart Disease /
Seizure/ Convulsion/ Epilepsy /
Pulmonary Tuberculosis /
Previous Hospitalizations/Surgeries/Operations (including Minor operations) /
Blurring of Vision or Error of Refraction /
Any Medication/s taken daily /
Chicken pox/Varicella /
Tattoo/Identifying marks /
Behavioral / Adjustment / Psychiatric Disorder /
Others /
FAMILY HISTORY
Do your FAMILY MEMBERS (grandparents, parents, siblings) have history of:
Hypertension/ Highblood /
Diabetes /
Heart Disease /
Asthma /
Heart Attack before 40 years old /
Sudden death/ Unknown Cause of Death /
Seizure/ Convulsion/ Epilepsy /
Stroke or Aneurysm /
Mental Illness /
Cancer /
Others /
PERSONAL AND SOCIAL HISTORY YES NO REMARKS
Do you smoke? /
Do you drink? /
Do you have allergies?
Allergies to food? /
Allergies to drug/ medicines? /
Others /
OBSTETRICS AND GYNECOLOGIC HISTORY (FOR FEMALES ONLY)
When was your last menstrual period? / May 6, 2019
Do you have dysmenorrhea? / Yes, before and during menstrual period
Are you expecting to be pregnant? /
Is your menses regular? / Yes
Any history of missed menses? /
VACCINATION HISTORY : Please check all vaccines that you have received and specify the date or atleast the year.
/ Tetanus Toxoid Last dose: 2016 (Any booster within the last 10 years)
/ Varicella - (Atleast 2 doses if you have not had a chickenpox)
/ MMR 2016 Booster 2016
Quadrivalent Flu Last dose: (given yearly)
/ Hepatitis B 2016 Booster
Pneumococcal
Anti-Rabies
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P.E. No.:0000003106
REVIEW OF SYSTEMS
AT PRESENT, Do you/ Do you have/ Do you feel...
Fever? Headache? Dizziness? /
Cough? Colds? Sore Throat? /
Blurring of Vision? /
Hearing Loss? /
Body Pain? Easy Fatigability? /
Chest Pain? /
Shortness of Breath? Difficulty of Breathing? /
Wake up at night due to difficulty of breathing or choking sensation? /
Abdominal Pain? Diarrhea? Constipation? /
Difficulty in urination? Frequent urination? /
Edema ("Manas") /
Rashes? Skin Changes? Cyst or Mass ("Bukol")? /
Other Conditions not mentioned above? /
I attest that I have answered above questions completely and truthfully.
ANA KRISTINA BAUTISTA VIZCARRA Date: MAY 20, 2019
Signature over Printed Name
To be completed by the physicians on duty:
Vital Signs:
BP: CR: RR: OS: OD:
T: Ht: Wt: BMI: CV:
Subjective Complaints:
Laboratory Results: Remarks
CBC Normal Abnormal
Urinalysis Normal Abnormal
Fecalysis Normal Abnormal
Chest X-ray (PA) Normal Abnormal
HBsAg Reactive Non-Reactive
Anti-HBs Reactive Non-Reactive
Drug Test Negative Positive
ECG Normal Abnormal
Pregnancy Test Negative Positive
Others
Pertinent P.E.: Remarks
HEENT Normal Abnormal
Chest/Lungs Normal Abnormal
Heart Normal Abnormal
Abdomen Normal Abnormal
Skin Normal Abnormal
Extremities Normal Abnormal
Breast Normal Abnormal
Anal Normal Abnormal
Assessment: Recommendations:
Advise for: Final Result:
Hepatitis B 1st dose 2nd dose 3rd dose Booster Fit
Varicella B 1st dose 2nd dose Fit w/ minor ailments
TD Booster Pending due to
MMR Pneumococcal Unfit
Quadrivalent Flu Meningococcal Others:
PHYSICIAN: DATE:
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