UNIVERSITY HEALTH SERVICES

19 April 2024

Dear First Year Student,

Congratulations on your acceptance to the Ateneo de Manila University!

In preparation for your registration this school year, I would like to inform you that we will be using an
electronic format for our health records. Upon confirming your intent to enroll at the Office of Admission
and Aid, you will be assigned an Ateneo email account. You will be asked to create your personal health
record through this link https://bluepass.ateneo.edu/ using your Ateneo email account. The health record
should be accomplished by July 1, 2024. Please take note that creating your account and uploading your
medical requirements are part of the steps prior to your enrollment to first year.

Guidelines for Health Requirements

• A physical examination signed by your attending physician using the medical assessment
form attached. The form may also be downloaded from the BluePHR site.
• If during the Physician’s physical examination (PPE), the student has been found to have a
treatable medical illness, prompt intervention is encouraged and eventual certification of treatment
and fitness to enroll from the attending physician is required.
• If during the PPE, current medical conditions are noted, e.g. hypertension, diabetes, breast mass,
severe scoliosis, learning disabilities or psychoemotional conditions or other conditions, the student
should present a separate medical certificate certifying the student’s fitness for enrolment using
the letterhead of the attending physician, duly stamped, and signed, containing the following
details:
• Complete name of the attending physician
• License number
• Complete clinic address and telephone number
• Findings and Plans for Management, and a statement of Fitness to enroll.
• Official result of a recent Chest X-Ray Examination. The Chest X-Ray should be taken within 6
months from the time of PPE, and results noted by your attending physician with a photocopy of
original documents.
• Certification of the completed immunizations from your attending physician:
 Hepatitis B (Documentation of at least three doses)
 Measles-Mumps-Rubella (MMR 2 doses)
 Chicken Pox (2 doses)
 Tetanus-diphtheria Booster (Last dose not more than 10 years ago)
 COVID-19 vaccination (1-2 doses, depending on the vaccine, Booster if available)

If any of the required immunizations are not complete at the time of submission, please request a schedule
for completion from the doctor. Pending immunization certificates should be completed and submitted
within the semester. If these vaccines have been accomplished but certification is unavailable, you may

College Clinic, SS105 G/F Social Sciences Building, Ateneo de Manila University
Katipunan Avenue, Loyola Heights, 1108 Quezon City, Philippines
+63(2)8426-6001 loc 5110, +63(2)8332-4434, [email protected]
Ateneo de Manila University Higher Education Office of Health Services
Loyola Heights, Quezon City Loyola Schools

MEDICAL ASSESSMENT FORM

Name: _____________________________________________________ ID Number ________ Year & Course ____________
Last First Middle
This medical assessment form is a requirement for entry into the university. For students with active comorbid condition, it is best for the medical
assessment to be completed by the physician directly managing the condition.
Section 1: Medical and Family History [To be completed by the parent or guardian.] This section needs to be reviewed by the physician.
Please check if the student or his/her siblings, parents or grandparents
History of Confinement: (Pls. specify date, diagnosis, and any pertinent
has/have or had any of the following. [Legend: STU-Student SIBS-Siblings
details.)
PAR-Parents GPS-Grand Parents]
ILLNESS STU SIBS PAR GPS _______________________________________________________________
Allergy, Hives (Specify) _______________________________________________________________
Allergic Rhinitis _______________________________________________________________
_______________________________________________________________
Asthma (Date of Last Attack) _______________________________________________________________
Tuberculosis
Alcohol History
Other Lung Problems (Specify) How often do you drink alcoholic beverages ___________________________

Hypertension or High Blood Smoking History – Please encircle answer:

Is the student a CURRENT or PREVIOUS smoker? YES NO
High Cholesterol, Lipids or Fats Age of onset of smoking: _________________________________________
How many sticks per day? _________________________________________
For Female Students:
Stroke or Heart Disease before Menarche: _____________________________________________________
the age of 40 yrs. old Last Menstrual Period: ___________________________________________
OB Score (if with previous pregnancy): _____________________________

Other Heart Disease before the

Does your son/daughter currently have special needs that can affect his or
age of 40 yrs. old
her academic performance or social adjustment in the University?
Anemia ___ Yes ___ No

Bleeding Problems If yes, what are these? Please check the appropriate space and kindly
specify the condition.
Thyroid Problems

Diabetes ___ Physical limitations (e.g. Cerebral palsy, paraplegia, problems with
ambulation, heart problems, others)
Hepatitis/ Jaundice Please specify: ______________________________________

Other Liver Problems (Specify) ___ Emotional or behavioral conditions (e.g. obsession-compulsion,
personality problems, anxiety, depression, Asperger’s syndrome, others)
Acid Peptic Disease/ Ulcers Please specify: ______________________________________
Other Stomach/ Intestinal
Problem (Specify) ___ Conditions related to attention or concentration (e.g. ADHD,
Kidney or Urinary Problems others)
(Specify) Please specify: _____________________________________

Dizziness/Fainting ___ Ongoing or long-standing medical conditions (e.g. seizures or

epilepsy, diabetes, others)
Recurrent Headache/ Migraine Please specify: _____________________________________

Convulsions or Seizures ___ Other special needs

Please specify: _____________________________________
Eating or Nutritional Problems

Alcohol or Drug Abuse For any of the conditions above, please specify details and provide any
documentation/work-up and clearance from your certified healthcare
Other psycho-emotional provider.
Problems
Is your son/daughter receiving professional services for this condition?
Anxiety & Mood Problems
___ Yes ___ No
Suicidal Thoughts
If yes, may we ask your permission to contact the health professional so
Depression we can coordinate with him/her the care and services for your
son/daughter if it is necessary? ___ Yes ___ No
Cancer (Specify)
Name of Health Professional: _____________________________________
Surgeries Undertaken (Specify) Field of Specialization: ___________________________________________
______________________________________________________________
Office Address: _________________________________________________
Any Other Active medical
Office Contact No. _______________________________________________
conditions (Specify)
Mobile No.: ___________________ Phone No.: _______________________

If the student is diagnosed with any medical condition, please provide Current medicines being taken by student:
details below. For any active conditions, a medical certificate with an ______________________________________________________
update of the current status of the patient is required. ______________________________________________________
______________________________________________________ ______________________________________________________
Name: _____________________________________________________ ID Number ________ Year & Course ____________
Section 2: Physician’s Assessment [This section should be completed by the examining physician.]

Section 2.1: Physical Examination

1. Height: ____________ cm or ____________ ft& in
Section 2.2: Immunization (Required) please provide
2. Weight: ____________ kg or ____________ lbs documentation so the examining physician can complete this
3. BMI: _______________________________________ section.
4. PR: ________________________________________
5. RR: ________________________________________ Vaccines Date Date Date Other forms of
6. Blood Pressure: ______________________________ (mo- (mo- (mo- Documentation
7. Temperature: _______________________________ day-yr) day-yr) day-yr) (Date & Result
8. Vision of Serology or
Date of Actual
Disease)
Uncorrected Corrected
Required Immunizations:
Right (OD)
Hepatitis B
Left (OS) (Three doses)
Both Eyes (OU)

9. Hearing (Gross Examination): __________________

Measles-
Note: For the physical exam, please check the correct column Mumps-
or write NE if not examined. Rubella
(Two doses)
Remarks or Details
Organ System Normal Abnormal
(If Abnormal)
10 Eyes Chicken Pox
(Two doses)
11 Ears
12 Nose
13 Throat
14 Mouth
Tetanus-
15 Teeth & Gums Diphtheria
16 Neck Booster (Td,
Tdap)
17 Thyroid
(within 6-10
18 Breast yrs)
19 Chest COVID-19
Vaccination
20 Lungs
21 Heart
22 Abdomen RECENT CHEST X-Ray (Required; within 6 months from the
External submission date. For any abnormal findings, clearance from
23 your attending physician is required.)
Genitalia

24 Back/ Spine Please attach official chest x-ray result

Upper
25
Extremities Date Done: ____________________________________________
Lower Name of clinic/hospital:
26
Extremities ______________________________________________________
Muscles & ______________________________________________________
27 ______________________________________________________
Joints
28 Skin
Impression/ Recommendation: ____________________________
______________________________________________________
Neurologic
29 ______________________________________________________
Exam
______________________________________________________
______________________________________________________
30. Blood Type (optional) _________________
Name: _____________________________________________________ ID Number ________ Year & Course ____________
Section 3: General Assessment and Recommendations [To be completed by the examining physician.]

Please provide an assessment of the health and well-being of the student based on your history and examination:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Please check:
___ Medically cleared to register for college education.
___ Limited clearance to register for college education (Please explain below) Please provide separate Medical Certificate
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Please check:
___ Medically cleared to participate in physical education classes and in sports and athletic activities.
___ Limited clearance for P.E., sports and athletic activities. (Please specify and explain below) Please provide separate Medical Certificate
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Please check:
___ No special health and medical needs in school.
___ Requires special health and medical needs in school. (Please specify and explain below) Please provide separate Medical Certificate
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Section 4: Certification by Examining Physician

I have reviewed the above sections on Medical and Family History and the Student’s Immunization Record. The information in
these sections is accurate and correct to the best of my knowledge. I have also done a complete health assessment and physical
examination of the student on ___________________________ (date of examination) and certify to the veracity of the findings
documented above.

Signature over Printed Name of Physician: ______________________________________________ License No: ___________________

Complete Address of Clinic: __________________________________________________________________________________
Landline: _____________________ Mobile Number: ____________________________ E-mail: ___________________________

Please check:
___ This is the first time I am seeing the student for his/her health examination.
___ The student has been under my care since _____________________ (Please state duration of doctor-patient relationship).
 UNIVERSITY HEALTH SERVICES

submit results of serologic tests for the specific antibodies which may be done at your physician’s request.
If for any reason, vaccination is contraindicated, a medical certificate from your attending physician stating
the reason for non-vaccination is requested.

Note that apart from completion of the health requirements as mandated by the Commission on Higher
Education (CHED), we enjoin all students to be part of the effort to make the campus a safe place for all.

Thank you for your cooperation in making the school environment a safe and healthy place for all.

Sincerely,

(SGD) Ma. Henrietta Teresa O. de la Cruz, M.D.

Director
Higher Education Office of Health Services – Loyola Schools

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College Clinic, SS105 G/F Social Sciences Building, Ateneo de Manila University
Katipunan Avenue, Loyola Heights, 1108 Quezon City, Philippines
+63(2)8426-6001 loc 5110, +63(2)8332-4434, [email protected]