Date of Birth: Emp.

Name: APE Schedule:

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Residence: Owned Rented Yes No







POOR FAIR GOOD
SOURCES OF STRESS:
BRIEF JOB DESCRIPTION:
BRIEF JOB DESCRIPTION:
ADULT MEDICAL ILLNESSES: (allergies to food and drugs, heart disease, hypertension, cancer, diabetes, mental illness, asthma, PTB, renal disease)
Menarche (1st menstruation): years old Last menstrual period: Duration:
Interval: ____ day cycle Amount (how many pads/day): Dysmenorrhea YES NO
Total number of children: Miscarriages/Abortion: previous pap smear: YES NO
ST. LUKE'S MEDICAL CENTER
COMPREHENSIVE OCCUPATIONAL HEALTH AND ENVIRONMENTAL SAFETY SERVICES (COHESS)
Please fill-out this Health Assessment Form prior to your Annual Physical Examination (APE) schedule. Accomplished form must be emailed to
cohess.bgc@stluke.com.ph.
PERSONAL SOCIAL HISTORY
Father
Mother
ALIVE/DECEASED FAMILY HISTORY
No. of Children/Dependents:
Grandfather
Grandmother
Siblings:
Living with relatives
IF NO, HAVE YOU IN
THE PAST?
CAFFEINE/TEA
RECREATIONAL DRUGS
ALCOHOL
TOBACCO/CIGARETTE
ACCIDENTS / INJURIES:
MEDICATIONS/SUPPLEMENTS TAKEN:
MENSTRUAL/OB
HISTORY:
PAST MEDICAL HISTORY
CHILDHOOD ILLNESSES:
OPERATIONS/SURGERIES:
FREQUENCY
/ WEEK?
SINCE? YES
Age
NO
MEDICAL ISSUES: (e.g. heart disease, hypertension, cancer, diabetes, mental
illness, asthma, PTB, renal disease)
HOW MANY /
DAY?
JOB TITLE/ POSITION: NO. OF YEARS OF STAY:
JOB TITLE/ POSITION: COMPANY/INDUSTRY NAME:
PREVIOUS OCCUPATION: COMPANY/INDUSTRY NAME:
OCCUPATIONAL AND ENVIRONMENTAL HISTORY
CURRENT OCCUPATION:
Grandfather
Grandmother

NO. OF YEARS OF STAY:

PETS
EXERCISE/HOBBIES/SPORTS
CONTRACEPTION
WHAT KIND?
Emp. No.:
(mm/dd/yyyy)
SLEEP AVERAGE HOUR / NIGHT:
SLEEP QUALITY:
09/28/1988 10005975 ANGELICA ALDAY NAGUIT May 21, 2014
Lung Cancer

80
65
alzheimer's
alzheimer's
Brother
Brother

Occassional

1 5-7

Work

GLOBE TELECOM INC 1.5

Senior Engineer TELECOM
SAN MIGUEL CORPORATION TELECOM
Project Engineer 2
12 May 2 5
30
3
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