Roman Catholic Diocese of San Fernando of La Union

Commission on Diocesan Schools

P. Gomez St., City of San Fernando, La Union Tel. No: (072) 607- 4640 | Fax: (072) 888-2353
E-mail: cdslaunion03@gmail.com

MEDICAL & DENTAL CLINIC

Cumulative Form

Dear Parents / Guardians:

Please fill in this Personal Data Sheet completely and correctly because the data will be used to update
your child’s Cumulative Health Record Folder.
Kindly return the duly accomplished sheet to the class Adviser of your son / daughter on or
before____________

Thank you for your cooperation. Clinic Staff

CUMULATIVE HEALTH RECORD

I. PERSONAL DATA

Name of Students:

(Last Name) (First Name) (Middle Name)

Home Address:
____________________________________________________________________________________

Date of Birth: Religion:

Place of Birth: Nationality:
Sex:

II. FAMILY DATA

Marital Status of Parents: Please check (✓)

__Married__Separated__Widow\er__Remarried__Live-in__Single Parent
Guardian
Father Mother ___________
__Living__Deceased __Living__Deceased Relationship to Child

Name
Nationality
Religion
Occupation
Where Employed
Contact No.

III. MEDICAL HISTORY

a. INFECTIOUS

Yes No Date of Illness/ Date of Illness/

Additional Remark Additional Remark
Amoebiasis Mumps
Chicken pox Pertussis
Conjunctivitis Primary Complex
Diphtheria
 Dengue Fever Rheumatic Heart
German Measles Seasonal Influenza
Hepatitis A/B Shingles
Influenza (H1N1) Tetanus
Measles Typhoid Fever
Meningitis Others:

b. NON-INFECTIOUS
Yes No Date of Illness/ Yes No Date of Illness/
Additional Remark Additional Remark
Accident Epilepsy
Allergy Eye Problem
Anemia Febrile Convulsion
Asthma Gingivitis
Bleeding Tendency Hearth Disease
Congenital Hearth Kidney Disease
Disease
Diabetes Liver Disease
Dental Caries Operation/s
Ear Problem Tumor
Emotional Disorder Others:

c. IMMUNIZATIONS
VACCINE DATE OF VACCINATION
BGC
OPV
DPT Vaccine
Hepatitis A Vaccine
Hepatitis B Vaccine
Flu Vaccine
Measles Vaccine
Chicken pox Vaccine
MMR Vaccine
Pneumococcal Vaccine
Typhoid Vaccine
Covid-19 Vaccine
Others:

• Permission is granted to the School Clinic Staff to administer Emergency Care Treatment as medical
needs arises.
• The School Authority may take the child to the nearest Doctor or Hospital if needed (lifesaving) before
calling the Parents/Guardian.

This is to certify that all the information given above is correct and true to the best of my ability.

Privacy Notice

Commission on Diocesan Schools, put premium to the protection of data privacy. We will never share
your personal information with external groups and individuals but we may pass your details to the
DepEd who is observing the same courtesy.

________________________________________
Parent / Guardian Signature over Printed Name

Note: Some of the data written in this sheet are subjective to change; please make time to inform the clinic staff of the
necessary changes for their guidance. Thank you very much