ILOILO SCHOLASTIC ACADEMY

Brgy. San Rafael, Mandurriao, Iloilo City

www.isa.edu.ph

LEARNERS MEDICAL RECORD UPDATE

I.

PERSONAL INFORMATION

Learners Name: ___________________________________ Age: ______ Gender:

__________
Grade Level: _________________
Date of Birth:
______________________
Current
Home
Address:
__________________________________________________________
___________________________________________________________
_____
II.
EMERGENCY CONTACS
Name:
____________________________Relationship
to
learner
:________________________
Home
Address:
________________________________________________________________
_____________________________________________________________
____
Landline
No/s.:__________________________
Mobile
No/s.:___________________________
III.

MEDICAL INFORMATION
(Please write the pertinent medical information for the PAST TWO
(2) years)

Allergies
(Food, Drugs,
Environment)

Surgeries
Performed
(if any)

Hospitalization/s
(Year Admitted &
Diagnosis)

Vaccination
Record Update
(State the
Vaccine and the
date received)

_______________________________
Name & Signature of Parent/Guardian

_____________________
Date