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Republic of the Philippines Document Code: SDO-QF-SGOD-HAN-010

Department of Education
Revision: 00
Region III
Schools Division Office of Tarlac Effectivity date: 05-28-2018

Name of Office:
HEALTH RECORDS Health and Nutrition Unit

MEDICAL HISTORY MEDICATIONS


HYPERTENSION
BRONCHIAL ASTHMA
TYPE 2 DIABETES
ALLERGIES
VACCINATION RECORDS Flu vaccines: COVID-19 Vaccines:
1st: OCTOBER 07, 2021
2nd: OCTOBER 29, 2021
Pneumococcal vaccines Booster: MAY 30, 2022

CLINIC VISITS
DATE CHIEF COMPLAINTS ASSESSMENT/PHYSICAL RECOMMENDATIONS PHYSICIAN/NURSE
EXAMINATION SIGNATURE

NAME: CABARRUBIAS, CAMILLE B.


AGE: 33
ADDRESS: TUEC CAMILING, TARLAC
TEL PHONE NUMBER: 0945-728-4967
CCONTACT PERSON IN CASE OF EMERGENCY: EDEN B. CABARRUBIAS

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