Personal Information Name: Jed Manguera Status:Single Gender: [X] M [ ] F

Birthday: October 12 1990 Age:22 Address: Muntinlupa

Provincial Address (if different from above): Batangas Mobile Number: +639178951012 Emergency Contact Person:_______________________________________ Mobile Number: +639________________

Physical Statistics Eye Color:Brown Hair Color:Black Weight: 180lbs. Skin Tone: Medium BMI:____

Height:6ft.1in. (____cm)

Body Built/Dominant hand: Right Medical Information Blood type: Donor: [ ] Yes [X] No; if yes, date of last donation: location of last donation: no. of times donated: List of medications/drugs: Blood chemistry results (Date:__________): Low, Normal, High Sugar Level:_____normal_ Red Blood Count:normal Medical History Check List Blood Pressure:_normal_______ Cholesterol: Normal

Prepared for:____________________ Date: ____________________ Have you ever had: Scarlet Fever [ ]YES [X ]NO Meningitis [ ]YES [ X]NO Infectious Mononucleosis [ ]YES [ X]NO Tuberculosis [ ]YES [ X]NO Exposure to TB [ ]YES [ X]NO Malaria [ ]YES [ X]NO Bronchitis [ ]YES [ X]NO Pneumonia [ ]YES [ X]NO Pleurisy [ ]YES [ X]NO Hepatitis [ ]YES [X ]NO Bladder infections [ ]YES [ X]NO Rheumatic fever [ ]YES [ X]NO Kidney disease [ ]YES [ X]NO Hives [ ]YES [ X]NO Hay fever/sinusitis [ ]YES [X ]NO Asthma [ ]YES [ X]NO Emphysema [ ]YES [ X]NO Arthritis [ ]YES [ X]NO Back trouble [ ]YES [X ]NO High blood pressure [ ]YES [X ]NO Heart disease [ ]YES [ X]NO Anaemia [ ]YES [ X]NO Bleeding tendency [ ]YES [ X]NO Nose bleeds [ ]YES [ X]NO Ulcer [ ]YES [ X]NO Cancer [ ]YES [ X]NO Haemorrhoids [ ]YES [ X]NO Blood transfusion [ ]YES [ X]NO Diabetes [ ]YES [ X]NO

Family History

Has any blood relative had any of the following: Anaemia [ ]YES [ ]NO Repeated infections [ ]YES [ ]NO Chronic lung disease [ ]YES [ ]NO Kidney disease [ ]YES [ ]NO Severe allergies [ ]YES [ ]NO Convulsions or seizures [ ]YES [ ]NO Diabetes [ X]YES[ ]NO Obesity [ X]YES [ ]NO Peptic ulcer [ ]YES [ ]NO Cancer [X ]YES [ ]NO Gallbladder Disease [ ]YES [ ]NO Leukaemia [ ]YES [ X]NO Crippling arthritis [ ]YES [X ]NO HB pressure [ ]YES [ X]NO Asthma [ ]YES [ X]NO Mental illness [ ]YES [X ]NO Migraine headaches [ X]YES [ ]NO Gout [ ]YES [ X]NO Thyroid trouble [ ]YES [X ]NO Chronic diarrhoea [ ]YES [X ]NO Suicide [ ]YES [ X]NO Alcoholism [ ]YES [X ]NO

Injuries Head Abdomen Back [ ]YES [X ]NO [ ]YES [ X]NO [ ]YES [ X]NO Chest Broken bones Other [ ]YES [ X]NO [ ]YES [X ]NO [ ]YES [ ]NO

*Specify:__Deviated Septum_____ Others Allergies [ ] Skin infections [ ] Surgeries/Operations [ X]

Vision Screening KEY: ONLY Screening Date: FAR BOTH EYES RIGHT EYE LEFT EYE Dominant eye: _____Left_____________________________ Examiner:______________________________________ Instruments Used:_______________________________ REMARKS: P = PASS or F = FAIL Recheck Date: FAR NEAR

NEAR

Activities/Hobbies/Sports during childhood (At least 10): 1. Basketball 2. Athletics 3. Volleyball 4. Football(soccer) 5. Swimming 6. Video Games 7. Camping 8. Outdoor games 9. Taekwondo 10. Tennis