MOTHER TERESA ACADEMYOF MARILAO, BULACAN INC.

PRESENT MEDICAL CONDITION

STUDENT HEALTH RECORD

S.Y. 20 - 20
Name:_____________________________ Grade: ____
Address:______________________________________
Gender:_______ Birthday:____________ Age:____
Height:______cm Weight:_________kg
CLINIC VISIT
BMI:_______-_________________________
DATE COMPLAIN INTERVENTION
FAMILY REATED MEDICAL HISTORY
DISEASES
Asthma ( ) Record of Illnesses:
Cancer ( )
Diabetes ( )
Tubercolosis ( )
Neurological Disease( )
Heart Disease ( ) Allergy:
Liver Disease ( )
Kidney Disease ( )
Other please specify: Hx of Hospitalization:
___________________ Guardian:___________________________
___________________ Contact No.:_________________________
___________________ Adviser:____________________________
School Nurse: NIKKO S. CARILLO RN, LPT