STUDENTS’ MEDICAL AND HEALTH HISTORY FORM

DEMOGRAPHIC PROFILE
Name: Eazel Donn O. Villamater
Grade and Section: 12- Faith
Address: Spielberg St., Brgy. Kulapi, Calmar Subd. Ph. 3 Lucban, Quezon
Age: 18 Sex: ☒Male ☐Female
Birthday: February 04, 2003
Height (cm): 168 cm Weight (kg): 78 kg
Phone Number: 09157992836
Guardian 1: Edsel A. Villamater Contact No.: 09174514807
Guardian 2: Marivel O. Villamater Contact No.: 09167119531

MEDICAL AND HEALTH HISTORY

Tick the box that applies. ☐ Chronic Illness
☐Any significant past injuries ☐ Hospitalization/Concussions
☐ Allergies, asthma, or wheezing ☐ Bone or Joint Injuries
☒ Contact lenses/Glasses ☐ Current on all vaccinations
☐ Currently on medication/s
☐ Others: Please specify. ___________________________________________

___EAZEL DONN O. VILLAMATER_____ ____EDSEL A. VILLAMATER ___

Signature over Student’s Printed Name Signature over Guardian’s Printed Name

__ 09/17/2021_______ ____ 09/17/2021____

Date Date

Prepared by: Mr. Ian Michael B. Lopez

PEH03, Instructor