UNIVERSITY OF MAKATI

J.P. Rizal Extension West Rembo, Makati City 2x2

MEDICAL AND DENTAL OFFICE
Medical and Dental Record

Date: April 10, 2019 Department: HIGHER SCHOOL NG UMak

Name: GRANT DHEL CASIMERO MONTECILLO  Age: 17 
Address: 919 MARINDUQUE ST PITOGO MAKATI CITY  Date of Birth: May 28 ,2001 
Civil Status: Gender: M 
Person to be Notified in case of emergency: EVANGELINE C. Contact Number of Guardian:
MONTECILLO  Address of Person to Notify: 919 MARINDUQUE ST PITOGO
Relationship: MAKATI CITY

MEDICAL HISTORY
Have you had any of following diseases?
(Please check the box/es)
Blood Type:
Allergy (food/Meds) Epilepsy (Pangingisay) Kidney Disease Bronchial Asthma (Hika) Arthritis
Mumps (Beke) Typhoid Fever(Tipus) Hypertension Heart Disease Pneumonia
Measles (Tigdas) Malaria Diabetes Mellitus Dengue Fever Tuberculiosis
Chicken Pox (Bulutong) Hepa A( )   Hepa B( )   Liver Disease( ) Surgical Operations:_________________

Do not write below this line, to be filled up by Medical Personnel only

DENTAL ASSESSMENT/EXAMINATION
LEGEND:
C=Carries
TX=For Extraction
RCT=Root Canal Treatment
Am=Amalgam
TF=Temporary Filing
CF=Composite Filing
P=Pontic
PJC=(Porcelain/Plastic) Jacket Crown
Remarks:

University Dentist Signature

MEDICAL ASSESSMENT/EXAMINATION
Laboratories Submitted Height: Weight:
BMI:
Chest Xray:
V/A: OD(R): OS(L): w/C.L.()
CBC:
BP:
Urinalysis:
Fecalysis:
Neuro-Psych:
Drug Test:
Others:
Remarks:

University Physician Signature