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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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* Indicates required question
Student's Information
SURNAME
*
Your answer
GIVEN NAME
*
Your answer
MIDDLE NAME
*
Your answer
SUFFIX
Your answer
Sex
*
Male
Female
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
Your answer
City/Municipality
*
Las Piñas
Muntinlupa
Parañaque
Other:
Student's Mobile Phone Number/s
*
Your answer
Grade Level
*
Choose
Toddler
Nursery
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Special Education (SpEd)
Alternative Learning System (ALS)
Section
*
Choose
Our Lady of Lourdes
Queenship of Mary
Our Lady of Miraculous Medal
St. Gabriel
St. Michael
St. Gerard
St. Odilo
St. Bartholomew
St. James the Great
St. Jude Thaddeus
St. Lorenzo Ruiz
St. Mark
St. Matthew
St. Joseph
St. Thomas
St. Ambrose
St. Augustine
St. Francis of Assisi
St. Aloysius Gonzaga
St. Charles Borromeo
St. Gregory the Great
St. Dominic Savio
St. Pedro Calungsod
St. Vincent de Paul
St. Benedict
St. Jerome
St. John Bosco
St. Thomas More
St. John Paul II (HUMMS)
St. Leo I (STEM)
St. Leo II (STEM)
St. Silverius
St. John XXIII (HUMMS)
St. Simplicius (ABM)
St. Sixtus I (STEM)
St. Sixtus II (STEM)
St. Sixtus III (STEM)
Special Education
Alternative Learning System
Height in centimeters
*
Your answer
Weight in kilograms
*
Your answer
Parent/ Guardians' Information
Full Name
*
Your answer
Relationship
*
Your answer
Contact Number/s
*
Your answer
Email address of the Parent/ Guardian
*
Your answer
MEDICAL HISTORY
Since you were born, Have you been diagnosed with the following?
*
Please check all that may apply.
Hypertension
Heart Disease
Kidney Disease
Liver Disease
Diabetes mellitus
Bronchial Asthma
Immunodeficiency state
Cancer
Measles
Mumps
Chickenpox
Dengue
Other:
Required
If with allergies, please check all that may apply
*
If no allergies, kindly check "other" and write N/A.
Drug
Food
Insect
Latex
Mold
Pet
Pollen
Other:
Required
Have you sought medical advice from your private physician for the past 12 months?
*
This includes ophthalmologist, physical therapist and others.
Yes
No
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.
Your answer
Have you visited your dentist for the past 12 months?
*
Yes
No
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.
Your answer
Special Medications (maintenance meds for hypertension, diabetes, allergies and others)
*
If none, write N/A.
Your answer
Have you been diagnosed with COVID 19?
*
Yes
No
If YES, please indicate the date of positive RT PCR result
*
If no, write N/A.
Your answer
What was your Classification of COVID Infection?
Choose
Asymptomatic
Mild
Moderate
Severe
Critical
Have you been exposed to a family member/ relatives who was diagnosed with COVID 19?
*
Yes
No
If YES, please indicate the date of your exposure
*
If no, write N/A.
Your answer
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.
Your answer
Pneumonia Vaccine
*
Kindly indicate the date of your last shot.
Your answer
Cervical Cancer Vaccine
*
Kindly indicate the date of your last shot.
Your answer
Hepatitis A Vaccine
*
Kindly indicate the date of your last shot.
Your answer
Anti Rabies Vaccine
*
Kindly indicate the date of your last shot.
Your answer
Anti Tetanus Vaccine
*
Kindly indicate the date of your last shot.
Your answer
Chickenpox
*
Kindly indicate the date of your last shot.
Your answer
Measles
*
Kindly indicate the date of your last shot.
Your answer
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?
*
YES
NO
If YES, kindly write the reason.
*
Your answer
If NO, kindly write the reason.
*
Your answer
Preferred brand of COVID 19 Vaccine
*
Pfizer BioNTech
Oxford AstraZenica
Sinovac CoronaVac
Gamaleya Sputnik V
Bharat BioTech
Moderna
Novavax
Janssen/ Johnson & Johnson's
Other:
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.
*
I AGREE
I DISAGREE
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