MOTHER TERESA ACADEMYOF MARILAO, BULACAN INC.

STUDENT HEALTH RECORD

S.Y. 20 - 20
Name:______________________________________ Grade and Section: ____________ Gender:________
Address:______________________________________ Age:____ Birthday:________________
Height:______cm Weight:_________kg BMI:__________-_______________________________

FAMILY REATED DISEASES MEDICAL HISTORY

Asthma ( ) Record of Illnesses:
Cancer ( )
Liver Disease ( )
Diabetes ( )
Tubercolosis ( ) Allergy:
Neurological Disease( )
Heart Disease ( ) Hx of Hospitalization:
Kidney Disease ( )
Other please specify:
_________________________________

PRESENT MEDICAL CONDITION

CLINIC VISIT
DATE COMPLAIN INTERVENTION

Guardian:_________________________________ Adviser:________________________________
Contact No.:_______________________________ School Nurse: NIKKO S. CARILLO RN, LPT