JCSGO CHRISTIAN ACADEMY

School Health Services

STUDENT HEALTH FORM

Student’s Name:__________________________________________________________ Grade & Section:___________

Last First Middle Name
Sex: __ Male __ Female Age:_____ Date of Birth:____________ Religion:____________ Nationality:____________
Home Address: ____________________________________________________________________________________
Student resides with:
Father’s Name:___________________________________________________ Tel/Mobile Number:________________
Mother’s Name:__________________________________________________ Tel/Mobile Number:________________

MEDICAL HISTORY
Allergies Epilepsy Mumps
Bronchial Asthma Heart disorder Psychoneurosis
Bleeding tendencies Hepatitis Tuberculosis
Chickenpox German Measles Others:
Convulsive disorder Kidney disease Previous hospitalization:
Diabetes Mellitus Hypertension

IMMUNIZATION (Check immunization completed)

BCG MMR Tetanus toxoid
DPT 1___ 2___ 3____ Hepatitis A COVID 19 1___ 2____
DPT Booster Hepatitis B COVID 19 Booster 1___ 2___
Oral Polio 1___ 2___ 3____ Influenza (Flu vaccine) Others:
OPV Booster HPV

PHYSICAL APPRAISAL
Height:_____ Weight:________ BMI:________ Interpretation:___________________

Specify any clinical diagnosis:

__________________________________________________________________________________________________
List of any substances/ medicines your allergic to
__________________________________________________________________________________________________

AUTHORIZATION
I agree that the information provided is true and correct to the best of my knowledge and understand that any dishonest
answers may have serious legal and public health implications under RA 11332.

_______________________________________ ________________________________
Signature over printed name of Parent/ Guardian Signature over printed name of Student

Noted by:

________________________________