ROSEVALE SCHOOL

STUDENT’S MEDICAL RECORD

Name: _____________________________________________________________________________________________
Last First Middle Nickname
Birthday: ______________________________________ Age__________________ Sex__________________
Home Addresss ____________________________________________________ Home Phone No._________________________
____________________________________________________
Father’s Name _________________________________ Occupation _____________________ Tel. No._____________________
Mother’s Name _________________________________ Occupation _____________________ Tel. No._____________________
Business Adds _________________________________________________________________ Tel. No._____________________
_________________________________________________________________

PAST HISTORY:
Student FREQUENTLY had: (please check)
_____ Abdominal Pain _____ Fever _____ Dizziness _____Chest pains
_____ Backpains _____ Nosebleeding _____ Sore throat _____Headache
_____ Easy fatigability _____ Colds _____ Others, please specify:__________________________

Past Diseases: (please check)

_____ Asthma _____ Hepatitis _____ Rheumatic fever _____ Worms
_____ Bleeding Tendencies _____ Measles _____ Primary Complex _____ Heart Problems
_____ Convulsions _____ German Measles _____ Urinary Tract Infection _____ Typhoid
_____ Chicken Pox _____ Mumps _____ Tonsillitis _____ Cough
_____ Allergy, please specify:____________________________________________________________________________________
_____ Others, please specify:____________________________________________________________________________________

Past Procedures and Operations done: ____________________________________________________________________________

Medications usually given in case of:

Fever ________________________ Headache ______________________ Eye discomfort________________
Colds ________________________ Stomach ache ______________________ Dysmenorrhea________________
Cough ________________________ Allergy ______________________ LBM_________________________

For PRESCHOOL ONLY: Please attach a photocopy of your child’s vaccination record.

Recently administered vaccines:

Name of vaccine date given
_____________________________ ______________________
_____________________________ ______________________
_____________________________ ______________________

Please note down any requests/comments regarding the child’s present health status:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

In case of emergency, please notify:

1._____________________________________________________ tel.no.__________________________________
2._____________________________________________________ tel.no.__________________________________

Name and Signature of Parent / Guardian: _____________________________________ Date:___________________