Student Health Registration Record

To Parent or Guardian:
In order to provide the best educational experience, the school personnel must understand your child’s health needs.
This form requests information from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).
Department of Health requires complete primary immunizations and a health assessment by a legally qualified practitioner of medicine
prior to school entrance. An immunization update and additional health assessments are required.

Please print
Student No:

Student Name(Last, First, Middle) Birth Date Male Nickname

Female

Address (Street, Town and ZIP code)

Parent.Guardian Name (Last, First, Middle) Home Phone Cell Phone

Parent.Guardian Name (Last, First, Middle) Home Phone Cell Phone

School/Level Race/ Ethnicity

Health Insurance / Number* / Philhealth* as dependent ❑ Filipino ❑ Others Please specify ______________________

Primary Care Provider / Family Doctor / Pediatrician and Contact Details, including Hospital/Clinic Affiliation

Do we have permission to call your pediatrician when we need to consult about your child's medical concern? Y N

Part I - To be completed by parent/guardian.

Please answer these health history questions about your childs before the physical examination.
Please circle Y if "yes" or N if "no". Explain all "yes" answers in the space provided below.

Any health concerns Y N Hospitalization or Emergency Room visit Y N Concussion / Head trauma Y N

Allergies to food or bee stings Y N Any broken bones or dislocations Y N Fainting or blacking out Y N

Allergies to medication Y N Any muscle or joint injuries Y N Chest pain Y N

Any other allergies Y N Any neck or back injuries Y N Heart problems Y N

Any daily medications Y N Problems with running Y N Bleeding more than expected Y N

Any problems with vision Y N Any skin problems Y N Problems with breathing or coughing Y N

Uses contacts or glasses Y N Has only 1 kidney or testicle Y N Asthma Y N

Any problems with hearing Y N Excessive weight gain/loss Y N Seizure Y N

Any problems with speech Y N Dental problems Y N ADHD/ADD Y N

Nose bleed Y N

Please expalin all "yes" answers here or back page. For illnesses/injuries/etc., include the year ans/or your child's age at the time.

Is there anything you want to discuss with the school's health care provider? Y N If yes, explain:

Please list any medications your child will need to

take in school:
All medications taken in school required a seperate Medication Authorization Form signed by a health care provider and parent/guardian.

I give permission for release and exchange information on this form

between the school nurse/ health care provider for confidential use in _____________________________________________________________________
meeting my child's health and educational needs in school. Signature of Parent/Guardian Date
 Part II — Medical Evaluation
Health Care Provider must complete and sign the medical evaluation and physical examination
Student Name________________________________________ Birth Date_________________ Date of Exam________________
❑ I have reviewed the health history information provided in Part I of this form.
Physical Exam
Note: *Mandated Screening/Test to be completed by health care provider
*Height_____ cm. /_____ % *Weight_____ kg_____. / % BMI_____ /_____ % Pulse *Blood Pressure______

Normal Describe Abnormal Normal Describe Abnormal

Neurologic Neck

HEENT Shoulders

*Gross Dental Arms/Hands

Lymphatic Hips

Heart Knees

Lungs Feet/Ankles

Abdomen Skin
Screenings
*Vision Screening *Auditory Screening

Type: Right Left Type: Right Left

With glasses 20/ 20/ ❑ Pass ❑ Pass

Without glasses 20/ 20/ ❑ Fail ❑ Fail

❑ Referral made ❑ Referral made

TB: High-risk group? ❑ No ❑ Yes PPD date read: Results: Treatment:

*IMMUNIZATIONS
❑ Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED
*Chronic Disease Assessment:
Asthma ❑ No ❑ Yes: ❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent ❑ Severe Persistent ❑ Exercise induced
If yes, please provide a copy of the Asthma Action Plan to School
Anaphylaxis ❑ No ❑ Yes: ❑ Food ❑ Insects ❑ Latex ❑ Unknown source
Allergies If yes, please provide a copy of the Emergency Allergy Plan to School
History of Anaphylaxis ❑ No ❑ Yes Epi Pen required ❑ No ❑ Yes
Diabetes ❑ No ❑ Yes: ❑ Type I ❑ Type II Other Chronic Disease:
Seizures ❑ No ❑ Yes, type:
❑ This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience.
Explain: _______________________________________________________________________________________________________
Daily Medications (specify): _______________________________________________________________________________________
This student may: ❑ participate fully in the school program
❑ participate in athletic activities and competitive sports with the following restriction/adaptation:
❑ Yes ❑ No Based on this comprehensive health history and physical examination, this student has maintained
his/her level of wellness.

Signature of health care provider MD / PA Date Signed Printed/Stamped Provider Name and Phone Number
 Part III - To be completed by parent/guardian.
Please answer these immediate action plan.

*FIRST AID

❑ I authorize the school nurse of The Philippine Montessori Center to administer to my child, the following medications
and give immediate action if the need arises: (Please check all that apply)
*For fever: *For acute asthma attack: *For cuts/wounds: *For allergic reactions:
mg/ml Dosage mg/ml
❑ Paracetamol (Tempra) ❑ Nebulize with NSS ❑ Antiseptic for minor skin ❑ Zyrtec
irritation

❑ Paracetamol (Calpol) ❑ Nebulize with salbutamol ❑ Betadine solution ❑ Allerzet

nebule (Ventolin)+NSS

❑ Paracetamol (Biogesic) ❑ Nebulize with salbutamol ❑ Hydrogen Peroxide ❑ Allerkid

nebule (Ventolin)

❑ Ibuprofen (Advil) ❑ Oxygen (upto 2L) ❑ Others (Please specify) ❑ Alnix

❑ Others (Please specify) ❑ Others (Please specify) ❑ Others (Please specify)

*AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

If emergency treatment is required for your child beyond that which our school nurse can address and you cannot be reached immediately, the school authorities will
use their own judgement in calling on the child's pediatrician and or bring your child to the nearest Emergeny Room:
❑ The Medical City Hospital (Pasig City)
❑ Cardinal Santos Hospital (San Juan City)
In case the parents cannot be reached, please indicate your alternative contact person.
Note: Excluding Parents and Pediatrician

Guardian 1 Guardian 2

Name: ___________________________________________________________ Name: ___________________________________________________________

Address: _________________________________________________________ Address: _________________________________________________________

_________________________________________________________ _________________________________________________________

Home Phone: _____________________________________________________ Home Phone: _____________________________________________________

Mobile Number: ___________________________________________________ Mobile Number: ___________________________________________________

Email Address: ____________________________________________________ Email Address: ____________________________________________________

Relationship to child:_______________________________________________ Relationship to child:_______________________________________________

The staff of The Philipppine Montessori Center (PMC) has permisssion to call my child's guardians and pediatrician when I cannot be reached. The staff of The
Philippine Montessori Center likewise has my permission to obtain immediate medical care if an emergency occurs when I cannot be reached
including taking my child to the emergency room.
1. PMC agrees to notify the parent/guardian whenever the child becomes ill, and parent/guardian agrees to have the child picked up
as soon as possible if so requested by PMC.
2. The parent/guardian agrees not to return the child to school without a certified medical clearance issued by the child's physician indicating that the
child has been cleared to return to school. If a medical certificate is provided, it should indicate a date that the child is allowed to return to school.
3. The parent/guardian agrees to inform PMC within 24 hours, or the next business day after the child or any member of the immediate household
has developed a reportable communicable disease.

Parent/Guardian Signature ________________________________________Date______________ Noted by Child's Physician__________________________________________

 To the Health Care Provider: Please complete and initial below.
Vaccine (Month/Day/Year) Note: *Minimum requirements prior to school enrollment.

Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6

BCG *

Hep B * * *

DTP/DTaP * * *

OPV * * *

IPV *

MMR *

Measles *

HIB

PCV

Rotavirus * *

Flu

Varicella *

Hep A

Meningococcal

Thypoid

PNEUMONIA
Japanese *
Encephalitis
Covid-19

Others

Disease Hx ________________________________________ ______________________ ________________________________________

of above (Specify) (Date) (Confirmed by)

Exemption
Religious_____________ Medical: Permanent_______________ Temporary___________ Date____________

Immunization Requirements for Newly Enrolled Students based on the National Immunization Program

KINDERGARTEN DTaP: At least 3 doses. The last dose must be given on or after 4th birthday

Polio: At least 3 doses. The last dose must be given on or after 4th birthday

MMR: 1 dose on or after the 1st birthday

Measles: Second dose of measles vaccine (or MMR), given at least 4 weeks after the first dose

Hib: Children less than 5 yrs of age need 1 dose at 12 months or older Children 5 and older do not need proof of Hib vaccination

Hep B: 3 doses

Varicella: 1 dose on or after the 1st birthday or verification of disease

Signature of health care provider MD / PA Date Signed Printed/Stamped Provider Name and Phone Number