SCHOOLS DIVISION OFFICE-MARIKINA CITY

Marikina District II
CONCEPCION INTEGRATED SCHOOL, SECONDARY LEVEL
J. P. Rizal Street, Concepcion I, District II, Marikina City
Tel. and Fax No. 576-7614 / 656-8404

STUDENT’S HEALTH STATUS RECORD FORM

LEARNER’S NAME:________________________________AGE: _____ SEX: ____BIRTHDATE: _________

MARITAL STATUS_________NATIONALITY __________ MOBILE/PHONE : ___________ LRN__________
GRADE/SECTION __________ ADVISER ___________________ YOUR PRINCIPAL ___________________
HOME ADDRESS:_________________________________________ e-mail add. ___________________
1. FATHER’S NAME: _______________________ 9.CONDITIONS WHICH COULD BE IMPORTANT IN
EDUCATION______________________________ AN EMERGENCY:(Please check ( √ )
OCCUPATION_______CONTACT NO. _________ □ Sever Asthma
2. MOTHER’S NAME: ______________________ □ Diabetes
EDUCATION______________________________ □ Seizures, Convulsions
OCCUPATION_______CONTACT NO. _________ □ Allergy, bites __________________________
3.GUARDIAN’S NAME: _____________________ □ Allergy, Medication _____________________
EDUCATION______________________________ □ Other________________________________
OCCUPATION_______CONTACT NO. _________ 10. Please check ( √ ) if you have any of the
4. HOW MANY SIBLINGS LIVING TOGETHER? following at present or during the past 14 days
BROTHER’S ____ SISTER’S ____ OTHER ______ □ Fever >37.5 C
5.LANGUAGE USUALLY SPOKEN AT HOME,PLS.√ □ Cough
TAGALOG___ ENGLISH___ OTHER____________ □ Difficulty of Breathing
6. DATE OF LEARNER’S PHYSICAL EXAM. □ Body weakness
________ □ Sore throat
7. DATE OF LAST VISIT TO DENTIST ____________ □ Headache
8.PERSONS TO BE NOTIFIED IN CASE OF □ Loss of smell of taste
EMERGENCY: □ Fatigue
1.____________________________________ □ Diarrhea
Relationship ___________________________ □ Body aches / pains –muscle and joints
Contact number __________________________ □ Colds and Runny nose
□ Nausea and Vomiting
2.____________________________________ □ Rashes
Relationship ___________________________ □ Butlig sa balat
Contact number __________________________ □ Pamumula ng Balat (Maaring Makati o hindi
□ Fully VACCINATED □ YES □ NO

11. HOUSEHOLD INFORMATION (Please complete for family and household members)
Please check ( √ ) BIRTH LIVES WITH CHILD FAMILY MEMBERS HEALTH PROBLEMS
DATE YES NO
FATHER:
MOTHER:
BROTHERS & SISTERS: (oldest first)
1.
2.
3.
4.
5.
6.
Other (specify relationship )
1.
2.
3.

(Use additional page if needed)

SSAT_1-L STUDENTS INDIVIDUAL HEALTH STATUS RECORD