VALENZUELA CITY STUDENT HEALTH PROFILE

PUBLIC SCHOOL PRIVATE SCHOOL

STUDENT BASIC INFORMATION
LAST NAME
FIRST NAME
MIDDLE NAME LRN / STUDENT NO
SUFFIX GENDER MALE FEMALE
BIRTHDAY (MM/DD/YYYY) CIVIL STATUS
CONTACT NUMBER EMAIL ADDRESS
NAME OF SCHOOL
GRADE SECTION
STUDENT CURRENT RESIDENCE
Unit/Bldg./House No.
STREET NAME BARANGAY
CITY / MUNICIPALITY
PROVINCE
STUDENT PERMANENT RESIDENCE
Unit/Bldg./House No./Bgy.
STREET NAME BARANGAY
CITY / MUNICIPALITY
PROVINCE
STUDENT MEDICAL HISTORY
WITH EXPOSURE TO COVID
PATIENT NO YES Date of exposure: _______________
ALLERGY WITH COMORBIDITY
NO ALLERGY DRUG HYPERTENSION
OTHER TYPE FOOD HEART DISEASE
For Other type, Please Write Below:
INSECT KIDNEY DISEASE
LATEX DIABETES MELLITUS
MOLD BRONCHIAL ASTHMA
PET CANCER
POLLEN OTHER/S ____________________
Has the student been diagnosed with COVID-19? If yes, please answer the following questions. If
not, please put N/A
Date of First Positive Result/Specimen Collection
(MM/DD/YYYY)
CLASSIFICATION OF COVID-19
PROVIDED ELECTRONIC INFORMED CONSENT ?
Information above verified and given by (Parent or Guardian):
Are you willing to have your child get vaccinated YES NO
against COVID 19 ?

FULL NAME AND SIGNATURE RELATION TO STUDENT

MOBILE/CONTACT NO. EMAIL ADDRESS DATE

Do not fill out this part (For Encoder and Verifier Only)
Encoder Name: Encoded Date: