HEALTH QUESTIONNAIRE

UST FACULTY OF MEDICINE AND SURGERY

Name: ______________________________________________ Date: _______________________

Sex: ________________
Date of Birth: ______________________________________

Please encircle the appropriate answer. If you answered “Yes” to any of the
questions below, please provide additional details if requested.

1. Do you have any contagious illness such as tuberculosis?

No. Yes. If yes, please specify:

2. Do you have any chronic or long-standing medical condition?

No. Yes. If yes, please specify:

3. Do you have any recurrent medical condition?

No. Yes. If yes, please specify:

4. Have you ever been tested positive for HIV/AIDS or any other sexually
transmitted disease?
No. Yes. If yes, please specify:

5. Do you have any allergies?

No. Yes. If yes, please specify:

6. Do you have any history of seizures or convulsions?

No. Yes.

7. Do you have a mental or neurologic disorder?

No. Yes. If yes, please specify

8. Do you have any heart condition or ailment?

No. Yes. If yes, please specify:

9. Do you have any blood pressure problems?

No. Yes.

10. Do you suffer from anemia?

No. Yes.

11. Do you have any history of stomach ulcers?

No. Yes.

Page 1/2
 12. Do you have liver disease?
No. Yes. If yes, please specify:

13. Have you ever been hospitalized for a medical condition?

No. Yes. If yes, please specify:

14. Have you ever been operated on for a medical or surgical condition?
No. Yes. If yes, please specify:

15. Do you take any prescription medications on a regular basis?

No. Yes. If yes, please specify:

16. Do you take any over-the-counter medications on a regular basis?

No. Yes. If yes, please specify:

17. Do you regularly smoke (e.g., cigarettes or cigars) or use electronic

cigarettes?
No. Yes. If yes, how often:

18. Do you regularly ingest alcoholic beverages?

No. Yes. If yes, how often:

19. Do you regularly or occasionally take prohibited drugs or dangerous drugs,

including those that have been prescribed by a licensed physician?
No. Yes. If yes, how often:

I declare that the answers that I provided are true and correct to the best of
my knowledge. It is understood that non-disclosure or misrepresentation of
facts in this health questionnaire may be grounds for revocation of my slot in
the medical school.

___________________________________________ ________________________________________
Name of Applicant Signature of Applicant

___________________________________________ ________________________________________
Name of Examining Physician Signature of Examining Physician

License No. ____________________________

PTR No. _________________________________

Page 2/2