Clinic
Content
INTERNATIONAL SCHOOL MANILA
University Parkway Fort Bonifacio, 1634 Taguig Metro Manila, Philippines Mailing Address: P.O. Box 1526 MCPO 1255 Makati City, Philippines Tel +632 840 8400 Fax +632 840.8405
Student Health Card and Physical Examination Record
This Health Card and the Physical Examination Record must be on file at the School Health Clinic on the date the student enters school. The child’s School Office must be notified of a guardianship anytime that parents leave Manila without their children.
FOR OFFICE USE: SCHOOL YEAR Photo 3 x 4 cm GRADE AGE
__________________________________
The information on this form will be treated as confidential and will only be shared with school personnel on a need-to-know basis.
STUDENT ID# ________________________ PLEASE PRINT THE INFORMATION REQUESTED BELOW
Student and Family Information
Student’s Name:
Family Name First Name mm dd yyyy Middle Name
Preferred Name: Date of Birth: _ ____/__ ___/__ ___ Both Parents Father Nationality: Mother Guardian
Gender: M / F
Student resides with:
FATHER / GUARDIAN’S NAME:
MOTHER / GUARDIAN’S NAME:
Home Address:
Home Address:
Home Phone #: Cell Phone #: Direct office line #: Office Phone #: Company Name: Languages Spoken:
Home Phone #: Cell Phone #: Direct office line #: Office Phone #: Company Name: Languages Spoken:
For Emergency (If Parents Cannot Be Reached)
Primary Contact: Secondary Contact: Local Doctor or Health Care Provider: Phone #: Phone #: Cell #: Cell #: Phone #:
NOTE: Please notify the Admission Office of any changes in phone numbers or contact persons
ISM Health Clinic Form Page 1 of 4
MEDICAL INFORMATION and HEALTH HISTORY
Allergies? Drug Allergies? Asthma? No No No Yes Yes Yes Reaction: Reaction: Does the student carry an asthma inhaler? No Yes No Yes Name of the medication/s and frequency: No Yes Ever had a serious respiratory reaction to a food, bee sting or a drug?
Is the student on regular medication:
Does the student need to take any medication/s during school hours?
(If so, a letter from the Medical Doctor must be kept on file in the School Health Clinic and the medication/s kept in the Clinic to be dispensed by the School doctor or nurse.)
Any other health condition that the school should be aware of, e.g. diabetes, epilepsy, etc.: Does the child have any present illness: No Yes
Past History: If Yes, give age and describe below. No
Skin Problem Diabetes Meningitis Tuberculosis Fainting Spells ADD / ADHD
Yes
Age
Asthma Heart Disorder Urinary Disorder Epilepsy Scoliosis Other Illness
No
Yes
Age
Describe: Hospitalization, Serious Injuries: Why? / When?
Eye glasses or contact lens: Hearing problem(s), multiple ear infections:
No
Yes No
Eye or vision problems, describe: Yes Describe:
PHYSICAL EXAMINATION – Mandatory for School Admission
To be completed by Licensed Physician, Nurse, Practitioner or Physician’s Assistant
Height (cm) Vision R L Weight (kg) Both Blood Pressure Blood Type, if known
Normal Eyes Ears Nose Throat Teeth
Abnormal Abdomen Genitalia Posture Joints Skin
Normal
Abnormal
ISM Health Clinic Form
Page 2 of 4
Normal Neck Lung Heart Describe Findings:
Abnormal Neurological Behavioral Emotional
Normal
Abnormal
Comments:
Able to participate in physical education activities: Restricted from certain sports:
No
Yes
Printed Name Address
Signature and Title
License Number Office Phone Number
Date
IMMUNIZATION RECORD TYPE
Anti TB-BCG Vacc.: (within 5 years) OR The following Tests: Mantoux Test within one year Tick Positive Negative If the above positive require: Chest X-ray Positive Negative
Please attach or complete schedule below...include dates for childhood vaccinations.
The tests / immunizations below are mandatory according to school policy and must be current before a student is admitted to ISM.
DATE
DATE
DATE
DATE
DATE
Please attach a copy of your child’s immunization record or complete the schedule including dates:
TYPE
DPT / DT Tetanus Polio Measles Mumps Rubella Typhoid / injection / oral every 3 years Tetanus-booster every 10 years Hepatitis A Hepatitis B Other vaccination/s
DATE
DATE
DATE
DATE
DATE
ISM Health Clinic Form
Page 3 of 4
DENTAL EXAMINATION RECORD
LEGEND: C M X RF U J P AM TF S W -
caries free caries missing tooth for extraction root fragment unerrupted tooth jacket crown pontic amalgam filling temporary filling sealant composite
Occlusion: Gingiva: Oral Hygiene: Remarks:
AUTHORIZATION
I give consent for my child to receive the following: NO * 1. Minor first aid (at the clinic) YES * 2. Emergency care (at the clinic) YES NO NO * 3. Emergency care at Makati Medical Emergency Room YES * 4. Oral non-prescription medication YES NO * NOTE: If “NO” to 1, 2, and/or 3 above, the student may not enter school until alternative emergency care instructions are on file with the School Health Clinic . I hereby authorize the ISM Dentist to give the following dental treatment to my child, as the need arises: 1. Annual oral examination YES NO NO 2. Emergency dental treatment YES Permission is hereby given for emergency measures to be initiated in case of accident or sudden illness with the understanding that I will be notified as soon as possible. I certify that all information given on this card is complete and correct. I acknowledge that it is my responsibility to inform the ISM School Health Clinic of any changes in my child’s health, physical condition or medical needs. Parent’s Signature: Date:
ISM Health Clinic Form Page 4 of 4
University Parkway Fort Bonifacio, 1634 Taguig Metro Manila, Philippines Mailing Address: P.O. Box 1526 MCPO 1255 Makati City, Philippines Tel +632 840 8400 Fax +632 840.8405
Student Health Card and Physical Examination Record
This Health Card and the Physical Examination Record must be on file at the School Health Clinic on the date the student enters school. The child’s School Office must be notified of a guardianship anytime that parents leave Manila without their children.
FOR OFFICE USE: SCHOOL YEAR Photo 3 x 4 cm GRADE AGE
__________________________________
The information on this form will be treated as confidential and will only be shared with school personnel on a need-to-know basis.
STUDENT ID# ________________________ PLEASE PRINT THE INFORMATION REQUESTED BELOW
Student and Family Information
Student’s Name:
Family Name First Name mm dd yyyy Middle Name
Preferred Name: Date of Birth: _ ____/__ ___/__ ___ Both Parents Father Nationality: Mother Guardian
Gender: M / F
Student resides with:
FATHER / GUARDIAN’S NAME:
MOTHER / GUARDIAN’S NAME:
Home Address:
Home Address:
Home Phone #: Cell Phone #: Direct office line #: Office Phone #: Company Name: Languages Spoken:
Home Phone #: Cell Phone #: Direct office line #: Office Phone #: Company Name: Languages Spoken:
For Emergency (If Parents Cannot Be Reached)
Primary Contact: Secondary Contact: Local Doctor or Health Care Provider: Phone #: Phone #: Cell #: Cell #: Phone #:
NOTE: Please notify the Admission Office of any changes in phone numbers or contact persons
ISM Health Clinic Form Page 1 of 4
MEDICAL INFORMATION and HEALTH HISTORY
Allergies? Drug Allergies? Asthma? No No No Yes Yes Yes Reaction: Reaction: Does the student carry an asthma inhaler? No Yes No Yes Name of the medication/s and frequency: No Yes Ever had a serious respiratory reaction to a food, bee sting or a drug?
Is the student on regular medication:
Does the student need to take any medication/s during school hours?
(If so, a letter from the Medical Doctor must be kept on file in the School Health Clinic and the medication/s kept in the Clinic to be dispensed by the School doctor or nurse.)
Any other health condition that the school should be aware of, e.g. diabetes, epilepsy, etc.: Does the child have any present illness: No Yes
Past History: If Yes, give age and describe below. No
Skin Problem Diabetes Meningitis Tuberculosis Fainting Spells ADD / ADHD
Yes
Age
Asthma Heart Disorder Urinary Disorder Epilepsy Scoliosis Other Illness
No
Yes
Age
Describe: Hospitalization, Serious Injuries: Why? / When?
Eye glasses or contact lens: Hearing problem(s), multiple ear infections:
No
Yes No
Eye or vision problems, describe: Yes Describe:
PHYSICAL EXAMINATION – Mandatory for School Admission
To be completed by Licensed Physician, Nurse, Practitioner or Physician’s Assistant
Height (cm) Vision R L Weight (kg) Both Blood Pressure Blood Type, if known
Normal Eyes Ears Nose Throat Teeth
Abnormal Abdomen Genitalia Posture Joints Skin
Normal
Abnormal
ISM Health Clinic Form
Page 2 of 4
Normal Neck Lung Heart Describe Findings:
Abnormal Neurological Behavioral Emotional
Normal
Abnormal
Comments:
Able to participate in physical education activities: Restricted from certain sports:
No
Yes
Printed Name Address
Signature and Title
License Number Office Phone Number
Date
IMMUNIZATION RECORD TYPE
Anti TB-BCG Vacc.: (within 5 years) OR The following Tests: Mantoux Test within one year Tick Positive Negative If the above positive require: Chest X-ray Positive Negative
Please attach or complete schedule below...include dates for childhood vaccinations.
The tests / immunizations below are mandatory according to school policy and must be current before a student is admitted to ISM.
DATE
DATE
DATE
DATE
DATE
Please attach a copy of your child’s immunization record or complete the schedule including dates:
TYPE
DPT / DT Tetanus Polio Measles Mumps Rubella Typhoid / injection / oral every 3 years Tetanus-booster every 10 years Hepatitis A Hepatitis B Other vaccination/s
DATE
DATE
DATE
DATE
DATE
ISM Health Clinic Form
Page 3 of 4
DENTAL EXAMINATION RECORD
LEGEND: C M X RF U J P AM TF S W -
caries free caries missing tooth for extraction root fragment unerrupted tooth jacket crown pontic amalgam filling temporary filling sealant composite
Occlusion: Gingiva: Oral Hygiene: Remarks:
AUTHORIZATION
I give consent for my child to receive the following: NO * 1. Minor first aid (at the clinic) YES * 2. Emergency care (at the clinic) YES NO NO * 3. Emergency care at Makati Medical Emergency Room YES * 4. Oral non-prescription medication YES NO * NOTE: If “NO” to 1, 2, and/or 3 above, the student may not enter school until alternative emergency care instructions are on file with the School Health Clinic . I hereby authorize the ISM Dentist to give the following dental treatment to my child, as the need arises: 1. Annual oral examination YES NO NO 2. Emergency dental treatment YES Permission is hereby given for emergency measures to be initiated in case of accident or sudden illness with the understanding that I will be notified as soon as possible. I certify that all information given on this card is complete and correct. I acknowledge that it is my responsibility to inform the ISM School Health Clinic of any changes in my child’s health, physical condition or medical needs. Parent’s Signature: Date:
ISM Health Clinic Form Page 4 of 4
