P.E. No.

:0000001114
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

SAN PEDRO, ANNA PAULA 20 FEMALE SINGLE ROMAN CATHOLIC FILIPINO

Address Contact No.

307 MANDALUYONG EXECUTIVE MANSIONS III G. ENRIQUEZ ST., BRGY. VERGARA MANDALUYONG 1551 09567108409
School / Course Application No.

MEDICINE MD1800662

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 /
Mental or Psychological Illness /
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 /
Others /
FAMILY HISTORY
Do your FAMILY MEMBERS (grandparents, parents, siblings) have history of:
Hypertension/ Highblood /
Diabetes / Mother
Heart Disease /
Asthma / Brother
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? / January 05, 2017
Do you have dysmenorrhea? /
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: 2015 (Any booster within the last 10 years)
/ Varicella 2009 (Atleast 2 doses if you have not had a chickenpox)
/ MMR 1997 2004 2012 Booster 2014
/ Quadrivalent Flu Last dose: 2017 (given yearly)
/ Hepatitis B 1997 2004 2013 Booster 2015

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P.E. No.:0000001114

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.

ANNA PAULA SAN PEDRO Date: JANUARY 21, 2018

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

Pertinent P.E.: Remarks

HEENT Normal Abnormal
Chest/Lungs Normal Abnormal
Heart Normal Abnormal
Abdomen Normal Abnormal
Skin Normal Abnormal
Extremities Normal Abnormal

Assessment: Recommendations:

Advise for: Final Result:

Hepatitis B 1st dose 2nd dose 3rd dose Fit
Varicella B 1st dose 2nd dose Fit w/ minor ailments
TD Booster Pending due to
MMR Unfit
Quadrivalent Flu Others:
for HBsAg the Hapatitis B Vaccine Series

PHYSICIAN: DATE:

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