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:
2nd:
Pneumococcal vaccines Booster:

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

NAME:TIFFANY D. DE VOTA
AGE:25
ADDRESS:#1070 PUROK 3 SAN FRANCISCO CONCEPCION, TARLAC
TEL PHONE NUMBER:09127114113
CONTACT PERSON IN CASE OF EMERGENCY: SAMUEL B. VILLELA

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