Learners Health Assessement Form

Republic of the Philippines
Department of Education
REGION III
SCHOOLS DIVISION OF BULACAN
MASAGANA HIGH SCHOOL
LEARNERS HEALTH ASSESSEMENT FORM

PART 1 HEALTH ASSESSMENT LRN ID#
To be completed by learners parent/guardian
Student's Name (Last, First, Middle) Birthdate Name of School Grade
(Mo., Day, Yr.)
Address (Number, Street, City, State, Zip) Phone No.
Parent/Guardian Names
Where do you usually take your child for routine medical care? Phone No.
Name: Address:
When was the last time your child had a physical exam? Month Year
When was the last time your child had a dental exam? Month Year
Where do you usually take your child for dental care? Phone No.
Name: Address:
ASSESSMENT OF STUDENT HEALTH
To the best of your knowledge, has your child had any problem with the following? Please check
Yes No Comments
Anaphylaxis
Allergies (Food, Insects,

Drugs, Latex)
Allergies (Seasonal)
Asthma or Breathing
Problems
Behavior or Emotional
Problems
Birth Defects
Bleeding Problems
Cerebral Palsy
Dental
Diabetes
Ear Problem or
Deafness
Eye or Vision Problems
Head Injury
Heart Problems
Hospitalization (When,
Where, Why)
Lead
Poisoning/Exposure
School Address: Masagana Pandi, Bulacan

Email Address: masagana.highschool@deped.gov.ph
Facebook: https://www.facebook.com/MASAGANIANS
REGION III
Learning
problems/disabilities
Limits on Physical
Activity
Meningitis
Prematurity
Problem with Bladder
Problem with Bowels
Problem with Coughing
Seizures
Serious Allergic
Reactions
Sickle Cell Disease
Speech Problems
Surgery
Other
Does your child take any medication? □ No □ Yes

Name(s) of Medications:
______________________________________________________________________________________________
Will your child require any medication to be administered in school? □ No □ Yes
Name(s) of Medications:
______________________________________________________________________________________________
Will your child require any emergency medications (epinephrine auto-injectors, inhalers, glucagon, Diastat, nebulized
medication) to be administered in school? □ No □ Yes, please list
______________________________________________________________________ Will your child require any special
treatments (G-tube feedings, catheterizations, etc.) to be administered in school? □ No □ Yes
Parent/Guardian Signature Date
PART II SCHOOL HEALTH ASSESSMENT LRN ID#

To be completed ONLY by Clinic Teacher/School Nurse
Student's Name (Last, First, Middle) Birthdate Name of School Grade
(Mo., Day, Yr.)
1. Does the child have a diagnosed medical condition? □ No □ Yes
Specify
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is at school? (e.g., seizure, severe allergic
reaction/ anaphylaxis to food or insect sting, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes, please
DESCRIBE. Additionally, please “work with the school nurse to develop an emergency plan”. □ No □ Yes
Specify
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
3. Are there any abnormal findings on evaluation for concern? □ No □ Yes

REGION III
Specify
_____________________________________________________________________________________________________________________
EVALUATION FINDINGS/CONCERNS
WN Area of
PHYSICAL EXAM ABNL HEALTH AREA OF CONCERN Yes No
L Concern
Head Attention Deficit/Hyperactivity
Eyes Behavior/Adjustment
ENT Development
Dental Hearing
Respiratory Immunodeficiency
Cardiac Lead Exposure/Elevated Lead
GI Learning Disabilities/Problems
GU Mobility
Musculoskeletal/Orthopedic Nutrition
Neurological Physical Illness/Impairment
Skin Psychosocial
Endocrine Speech/Language
Psychosocial Vision
Other
REMARKS: (Please explain any abnormal findings/health concerns.)
4. RECORD OF IMMUNIZATIONS FOR COVID19: required to be completed and attached by a health care provider or a computer-generated
immunization record must be provided.
5. Is the child on medication? If yes, indicate medication and diagnosis. □ No □ Yes
_____________________________________________________________________________________________________________________
Authorization to Administer Prescribed Medication, Release and Indemnification Agreement, must be completed for medication
administration in school).
6. Should there be any restriction of physical activity in school? If yes, specify nature and duration of restriction. □ No □ Yes
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
7. Screenings Results Date Taken
Tuberculin Test
Blood Pressure
Height
Weight

REGION III
BMI
Lead Test Optional
PART II SCHOOL HEALTH ASSESSMENT (continued)

To be completed ONLY by Clinic Teacher/School Nurse
(Student Name) ________________________________________________________________________ has had a complete physical

examination and has:
□ No evident problem that may affect learning or full school participation □ Problems noted above
Additional Comments:
Clinic Teacher/School Nurse Phone No. Date


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Republic of the Philippines

LEARNERS HEALTH ASSESSEMENT FORM

Address (Number, Street, City, State, Zip) Phone No.

Allergies (Food, Insects,

School Address: Masagana Pandi, Bulacan

Problem with Bladder

Problem with Bowels

Problem with Coughing

Does your child take any medication? □ No □ Yes

Parent/Guardian Signature Date

PART II SCHOOL HEALTH ASSESSMENT LRN ID#

1. Does the child have a diagnosed medical condition? □ No □ Yes

School Address: Masagana Pandi, Bulacan

Cardiac Lead Exposure/Elevated Lead

Neurological Physical Illness/Impairment

REMARKS: (Please explain any abnormal findings/health concerns.)

School Address: Masagana Pandi, Bulacan

Lead Test Optional

PART II SCHOOL HEALTH ASSESSMENT (continued)

(Student Name) ________________________________________________________________________ has had a complete physical

Clinic Teacher/School Nurse Phone No. Date

School Address: Masagana Pandi, Bulacan

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