Stratford International School

J. Catolico Avenue, Lagao, General Santos City

Tel. Number: (083) 554-1615 email address: stratfords@gmail.com

PERSONAL AND MEDICAL INITIAL HISTORY SHEET

Name: _________________________________________________ Date: ______/ ______/ ______
Present Address: ____________________________________________________________________
Contact Number: __________________ Date of Birth: ______/ ______/ ______ Age: ____________
Height: __________________________ Weight: __________________________
Parent/ Guardian: _______________________________ Relation: _________________________
Address: _________________________________________ Contact Number: __________________

PERSONAL DATA:
Do you have Health Insurance or Philhealth? _____ Yes _____ No
Name and ID Number: _______________________________________________________________
Private Doctor: _____________________________________________________________________
What kind of medical care have you received in the last year? _______________________________
Medication used in the last year: _______________________________________________________

IMMUNIZATION:
(Rubella/ MMR, Tuberculosis, Hepatitis B, Diptheria, Tetanus Toxoid, Polio Vaccine, and Meascles)
Complete: ________________ Incomplete: ________________ (Please specify what kind of vaccine)
Blood Type: _________________________

PERSONAL HEALTH HISTORY:

Do you have, or have you ever had any of the following:
ILLNESSES YES NO
Frequent of Severe Headaches
Seizures or Fainting Spells
Vision Problems
Chest Pain or Difficulty Breathing
Cardiac Problems
Blood Disease
Stomach or Intestinal Problems
Kidney/ Bladder Problems/ Infections
Pain or Burning Sensation during Urination
Bowel Problems/ Bleeding/ Constipation/ Diarrhea
Depression
Numbness or Paralysis
High Cholesterol
Blood Clots or Varicose Veins
Others: (Please Specify) ______________________________________________________________
(For Nurse’s use only) Initial Medical History
Date: __________________ Weight: ___________________ Height: ____________________
Temperature: ___________ Blood Pressure: _____________ _ Heart Rate: _________________

EMERGENCY TREATMENT AUTHORIZATION:

In the event of an emergency when immediate observation or treatment is deemed necessary in the judgment of the
school nurse/ authorize and direct the school authorities to send my child to medical facility most readily accessible. I
shall not hold the school authorities liable for any expenses, claims, loss or damage that may arise as a result of such
action and shall indemnify the school for all expenses, losses and claims incurred by it in relation to such action.
Permission to administer Tempra/ Calpol/ Tylenol/ Neozep/ Anti-Histamine (Yes:___ No:___)

___________________________________________
Student Signature

____________________________________________ _______________________________________
Signature over Printed Name of Parent/ Guardian Date Signed

STATEMENT OF CONFIDENTIALITY:
This medical record is confidential and it will not be released to any person or organization outside of the school without
your written consent.

____________________________________________ _______________________________________
Signature over Printed Name of Nurse Practitioner Date Signed