DAO ELEMENTARY SCHOOL Health Profile

Health Declaration Form Comorbidity ( Kasalukuyang karamdaman )

( ) Diabetes ( ) Asthma
Date: __________ Temperature: __________ ( ) Heart Disease ( ) Hypertension
Full Name: _________________________________ ( ) Obesity ( ) Others
Specify:
Sex: ( ) Male ( ) Female Age: ________
Lagyan ng tsek (P) kung nakaranas ng mga sumusunod
Birthday: _________________________________ sa nakalipas na 7 araw at sa kasalukuyan
Contact
Number: _________________________________ ___ Lagnat ___ Sakit ng ulo
Complete
Address: _________________________________ ___ Ubo ___ Panghihina
___ Sipon ___ Pananakit ng
________________________ ___ Pagtatae lalamunan
Signature ___ Hirap sa Paghinga

DAO ELEMENTARY SCHOOL Health Profile

Health Declaration Form Comorbidity ( Kasalukuyang karamdaman )

( ) Diabetes ( ) Asthma
Date: __________ Temperature: __________ ( ) Heart Disease ( ) Hypertension
Full Name: _________________________________ ( ) Obesity ( ) Others
Sex: ( ) Male ( ) Female Age: ________ Specify:ng mga sumusunod
Lagyan ng tsek (P) kung nakaranas
Birthday: _________________________________ sa nakalipas na 7 araw at sa kasalukuyan
Contact
Number: _________________________________ ___ Lagnat ___ Sakit ng ulo
Complete
Address: _________________________________ ___ Ubo ___ Panghihina
___ Sipon ___ Pananakit ng
________________________ ___ Pagtatae lalamunan
Signature ___ Hirap sa Paghinga

DAO ELEMENTARY SCHOOL Health Profile

Health Declaration Form Comorbidity ( Kasalukuyang karamdaman )

( ) Diabetes ( ) Asthma
Date: __________ Temperature: __________ ( ) Heart Disease ( ) Hypertension
Full Name: _________________________________ ( ) Obesity ( ) Others
Sex: ( ) Male ( ) Female Age: ________ Specify:
Lagyan ng tsek (P) kung nakaranas ng mga sumusunod
Birthday: _________________________________ sa nakalipas na 7 araw at sa kasalukuyan
Contact
Number: _________________________________ ___ Lagnat ___ Sakit ng ulo
Complete
Address: _________________________________ ___ Ubo ___ Panghihina
___ Sipon ___ Pananakit ng
________________________ ___ Pagtatae lalamunan
Signature ___ Hirap sa Paghinga