St. Andrew's School Students' Health Assessment Form
The Health Assessment form aims to establish data on health status of students to serve as bases for planning health programs and services for Academic Year 2021 - 2022.

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Student's Information
SURNAME *
GIVEN NAME *
MIDDLE NAME *
SUFFIX
Sex *
Birthday *
Kindly indicate the date that your son/ daughter was born using this format. DAY/MONTH/YEAR (31/12/2001 - December 31, 2001)
MM
/
DD
/
YYYY
Current Residence *
Unit/ Building/ House No., Street Name, Purok, Zone, Subdivision and Barangay
City/Municipality *
Student's Mobile Phone Number/s *
Grade Level *
Section *
Height in centimeters *
Weight in kilograms *
Parent/ Guardians' Information
Full Name *
Relationship *
Contact Number/s *
Email address of the Parent/ Guardian *
MEDICAL HISTORY
Since you were born, Have you been diagnosed with the following? *
Please check all that may apply.
Required
If with allergies, please check all that may apply *
If no allergies, kindly check "other" and write N/A.
Required
Have you sought medical advice from your private physician for the past 12 months? *
This includes ophthalmologist, physical therapist and others.
If yes, kindly specify the date of consultation, diagnosis, hospital confinement and procedures undergone (e.g. x-ray, diagnostics, endoscopy, surgery, etc.) *
If no, write N/A.
Have you visited your dentist for the past 12 months? *
If yes, kindly specify the date of visitation and procedures undergone (e.g. oral prophylaxis, tooth extraction, orthodontic treatments, etc.) *
If no, write N/A.
Special Medications (maintenance meds for hypertension, diabetes, allergies and others) *
If none, write N/A.
Have you been diagnosed with COVID 19? *
If YES, please indicate the date of positive RT PCR result *
If no, write N/A.
What was your Classification of COVID Infection?
Have you been exposed  to a family member/ relatives who was diagnosed with COVID 19? *
If YES, please indicate the date of your exposure *
If no, write N/A.
IMMUNIZATION STATUS
Please WRITE the DATE of LATEST/LAST administration of the Vaccine

If you cannot recall the exact date, kindly indicate the year.

If not yet received, kindly write N/A.
Influenza Vaccine *
Kindly indicate the date of your last shot.
Pneumonia Vaccine *
Kindly indicate the date of your last shot.
Cervical Cancer Vaccine *
Kindly indicate the date of your last shot.
Hepatitis A Vaccine *
Kindly indicate the date of your last shot.
Anti Rabies Vaccine *
Kindly indicate the date of your last shot.
Anti Tetanus Vaccine *
Kindly indicate the date of your last shot.
Chickenpox *
Kindly indicate the date of your last shot.
Measles *
Kindly indicate the date of your last shot.
COVID 19 Vaccine Survey
If not applicable, please write N/A.
If COVID 19 Vaccines are now approved for children, are you willing to get it? *
If YES, kindly write the reason. *
If NO, kindly write the reason. *
Preferred brand of COVID 19 Vaccine *
CONSENT
I hereby authorize St. Andrew's School, Inc., to collect and process the data indicated herein for the purpose of updating students health records. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012. *
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