ROJoson Medical Clinic Form – 16jan3

Updated ROJoson Medical Clinic Form – January 3, 2016




Master of Science in Clinical Medicine; Master in Health Profession Education

ROJoson Medical Clinic

Patient’s General Data


Name _________________________________________________________________________

                    (Last name)                                (First name)                             (Middle name)


Birthday ___________Age ____Sr. Citizen TIN ______________Sex ___ Civil Status ________

Occupation _________________ Address ___________________________________________

Tel No. ______________Cell No. ____________________ Email _________________________

Relative _______________________ Relationship ________________ Cell No. _____________

Referred by _________________ Personal Account ___Health Insurance (specify) _________


Patient’s Declaration of Health Information (Pls. fill and sign below.)

Date of consult / declaration of information:

Primary reason for consult:

When symptom/s first noted:


Brief description of characteristics of present symptoms:


Previous medical consult and treatment (if yes, give details and provide photocopies of reports):


Taking blood thinning drugs such as aspirin, coumadin, clopidogrel and other drugs?


Known existing / past disease/s (if yes, give details):


I consult with an understanding and acceptance of the Policies and Procedures of ROJoson Medical Clinic explained and published in ttps://

Medicine is not an exact science! Medicine is a science of uncertainty and an art of probability! (Sir William Osler) I practice my medical profession factoring in the above precepts.

I don’t guarantee or give warranty for successful outcomes in my medical management.

Nevertheless, I do my utmost best in managing my patients so as to promote successful outcomes (resolution of the health problem with minimal side-effects as much as possible).

Reynaldo O. Joson, MD



Printed name and signature of patient or guardian (MUST accomplish!)


Medical Specialties of Dr. Reynaldo O. Joson

General Medicine; General Surgery; Surgical Oncology;

Head and Neck, Thyroid, Breast, Abdomen, Gallbladder, Stomach, Intestines, Hernia, Skin and Soft Tissue Disorders

(Do NOT fill below this line.)




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