Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
MACARANG NATIONAL HIGH SCHOOL
Macarang, Mangatarem, Pangasinan

STUDENT HEALTH RECORD

Dear Parents,
Attached is the copy of complete medical form for the students. The school clinic is required to keep the
student’s updated and complete medical data as part of the school health records and for emergency purposes.
We would like to ask you to provide us with data concerning your child’s past illnesses, immunizations,
surgeries (if any, and other health information that may be relevant to your child’s health.
Rest assured that our medical team will also inform you of any significant findings concerning your child that
may need further attention and that all data furnished will be treated with the utmost confidentiality.
Thank you for your cooperation.
Sincerely,
_______________________
School Nurse

STUDENT’S DEMOGRAPHIC DATA

Name:

LAST FIRST MIDDLE

Address:

Gender: ___________ Religion: _____________________________Nationality:

_________________________
Date of Birth: __________________________ Place of Birth:__________________________
Name of Parents: Father: ____________________________________Contact No.:_____________________
Mother: ___________________________________ Contact No.:_____________________
Person to be notified in case of
emergency:_______________________________________________________________________________
Contact No.:___________________________
In the event that emergency treatment is necessary,
I hereby authorize the Macarang NHS Nurse to bring
my child to the nearest clinic or hospital facility.

___________________________________________________________
Signature Over Printed Name of Parent/ Guardian

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 Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
MACARANG NATIONAL HIGH SCHOOL
Macarang, Mangatarem, Pangasinan

IMMUNIZATION
1. Kindly check the appropriate box for the immunizations your child has received:
VACCINE YES NO REMARKS
BCG
DPT
OPV/IPV
HEPATITIS B
HIB
FLU
ROTAVIRUS
MEASLES
MMR
TYPHOID
HEPATITIS A
VARICELLA
MENINGOCOCCAL
PNEUMOCOCCAL
HPV(anti-cervical ca)
INFLUENZA

2. COVID vaccination status:

• If your child has received COVID Vaccine, please indicate below:
COVID VACCINE BRAND DATE
ST
1 DOSE
2ND DOSE
BOOSTER

• If not vaccinated, please state the

reason:__________________________________________________________________________
________________________________________________________________________________
• Are members of the household vaccinated? YES____ NO_____
If not, why?
________________________________________________________________________________
________________________________________________________________________________
• Did you or any of the family contracted COVID? YES____ NO____
If yes, who and
when?_______________________________________________________________

MEDICAL HISTORY
• ALLERGIES:Kindly list your child’s allergies. Include foods, drugs, plants, animals.
ALLERGY REACTION TREATMENT

• MEDICATIONS:
o Does your child take medication at home on a daily basis? YES___ NO___
Medication _______________________Used for _______________Dose/Time_______________
Medication _______________________Used for _______________Dose/Time_______________

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 Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
MACARANG NATIONAL HIGH SCHOOL
Macarang, Mangatarem, Pangasinan

• In case of the following situations, what medicine can be given to your child by the nurse?
CONDITION MEDICATION DOSE REMARKS
Headache
Toothache
Fever
Allergy/ Rhinitis
Stomach ache
Other: Pls. Specify:

• Is your child receiving current or ongoing treatment for any medical, surgical or psychological condition?
YES ___ NO_____
If Yes, please give
details:_______________________________________________________________________________
____________________________________________________________________________________
• Is there any reason why your child cannot participate in Physical Education classes or intramural/
interscholastic sports? YES_____ NO____
If Yes, please give
details:_______________________________________________________________________________
____________________________________________________________________________________
• Visual Difficulties: YES ___ NO ____ Contact Lenses ____ Glasses ______
• Any previous difficulties with hearing, speech, or Language development? YES____ NO___
If Yes, please give
details:_______________________________________________________________________________
_____________________________________________________________________________________
• Please put check (✓) if your child has had the following conditions:
Backaches ______ Fainting spells ______
Chest pain ______ Headaches ______
Cough/ colds ______ Insomnia ______
Cyclic vomiting ______ Joint pains ______
Depression ______ Recurrent Abdominal pain ______
Difficulty of breathing ______ Seizure ______
Dizziness ______ Urinary problems ______
Epistaxis (Nosebleed) ______ Weight loss ______
Eczema ______ others, pls specify:_______________

• Please state any regulated/ prescription drugs that your child is taking at the moment or might have taken
in the past
PRESCRIPTION DRUG PERIOD TAKEN (month & year)

• Other medical/ health information you may wish to include that may help us understand your child’s health
needs:
_____________________________________________________________________________________
_____________________________________________________________________________________

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 Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
MACARANG NATIONAL HIGH SCHOOL
Macarang, Mangatarem, Pangasinan

MEDICAL WAIVER
1. Medical Permission
I hereby give permission for my child to be given temporary over-the-counter medication by the
school nurse. Medication used in the nurse’s office may include, but is not limited to,
Paracetamol for pain and fever, Cetirizine for allergies, Ibuprofen for pain relief, and some
homeopathic remedies, unless otherwise stated in Section Medical History under Medications of
this form.

I further understand that the student health office hours are from 8 AM to 4 PM only.

____________________________________________________
Signature over Printed Name of Parent/ Guardian/ Date signed

2. First Aid Treatment Permission

I understand all efforts will be made to contact parents first and if unavailable, I hereby give
permission for first aid measures to be initiated in case of a minor accident or sudden illness.

I certify that all information given is correct and complete.

____________________________________________________
Signature over Printed Name of Parent/ Guardian/ Date signed

3. For children with Asthma:

I understand that the school clinic has a nebulizer on hand. I agree to send nebules/ inhalers for
my child to the school nurse if my child might have an asthma attack. For hygienic purposes, I
also have to provide my child with the mouthpiece and tubing for personal use.

____________________________________________________
Signature over Printed Name of Parent/ Guardian/ Date signed