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Andabuen National High School: Benito Soliven South District

The medical referral form refers a student named [NAME] for chief complaint and impression to an address for treatment. It includes the student's age, sex, address, grade, and chief complaint as noted by the referring teacher. The medical treatment return slip is to be detached and sent back to the school with findings, action/recommendation, date, and doctor signature. The 2019 NCOV and health situation report is a report from the Andabuen National High School to the Region 02 Division of Isabela Schools Division Office regarding the NCOV and health situation. The health declaration form is a screening questionnaire for staff and visitors to the Andabuen National High School regarding COVID-19 symptoms, contact history

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Ronalyn Collado
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94 views3 pages

Andabuen National High School: Benito Soliven South District

The medical referral form refers a student named [NAME] for chief complaint and impression to an address for treatment. It includes the student's age, sex, address, grade, and chief complaint as noted by the referring teacher. The medical treatment return slip is to be detached and sent back to the school with findings, action/recommendation, date, and doctor signature. The 2019 NCOV and health situation report is a report from the Andabuen National High School to the Region 02 Division of Isabela Schools Division Office regarding the NCOV and health situation. The health declaration form is a screening questionnaire for staff and visitors to the Andabuen National High School regarding COVID-19 symptoms, contact history

Uploaded by

Ronalyn Collado
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

DEPARTMENT OF EDUCATION
Region 02
Division of Isabela
BENITO SOLIVEN SOUTH DISTRICT
ANDABUEN NATIONAL HIGH SCHOOL
Andabuen, Benito Soliven, Isabela

MEDICAL REFERRAL FORM

To _________________________________________________ Date:________________
Address: _______________________________________________________________________

This is to refer to you:


Name:_______________________________________ Age:______________ Sex:_______
Address/School:___________________________________________ Grade:_____________
Chief Complain:
_______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Impression: ____________________________________________________________________
Remarks:________________________________________________________________________
__________________________
Name & Signature

__________________________
Designation
__________________________________________________________________________________
Note: To be detached from upper portion and sent back to the school

_________________________
Name of Institution

MEDICAL TREATMENT RETURN SLIP

Returned to_______________________________________

Name of Patient__________________________________ Date Referred________________

Chief Complaint_________________________________________

Findings _________________________________________________________

Action/Recommendation _________________________________________

_________ ________________________
Date Name & Signature

_______________________
Designation
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region 02
Division of Isabela
BENITO SOLIVEN SOUTH DISTRICT
ANDABUEN NATIONAL HIGH SCHOOL
Andabuen, Benito Soliven, Isabela

2019- NCOV AND HEALTH SITUATION REPORT

Region
Schools Division Office
Report
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region 02
Division of Isabela
BENITO SOLIVEN SOUTH DISTRICT
ANDABUEN NATIONAL HIGH SCHOOL
Andabuen, Benito Soliven, Isabela

HEALTH DECLARATION FORM


Dear Sir/Mam:
To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our staff
and visitors, we are conducting a simple screening questionnaire. Your participation is important
to help us take precautionary measures to protect you and everyone in this agency. Thank you for
your time.
Name:
Age: Sex:
Personal Contact No.
Office:
Office Address:
Person/Office to visit:
Purpose of visit:
Temp.reading: Date: Time:
Recorded by staff(Name)

1. In the past 14 days, which of the following symptom(s) have you experienced, please
check () the relevant box(es)
{ } Fever { } Dry cough
{ } Sore throat { } Tiredness
{ } Diarrhea { } Shortness of breath
{ } Body Ache { } Runny Nose
{ } Headache { } Others
{ } NONE OF THE ABOVE
2. Have you been in contact with a confirmed COVID-19 in the past 14 days?
[ ] Yes [ ] No
3. Have you been identified to high risk areas of COVID- 19 in the past 14 days?
[ ] Yes [ ] No
If Yes, please indicate the area(s):
Declaration and Data Privacy Consent Form:
The information I have given is true, correct and complete, I understand that failure to answer any
question or giving false answer can be penalized in accordance with the law.

I voluntarily and freely consent to the collection and sharing of the above personal information
only in relation to the Deped Isabela COVID-19 protocols.

_______________________ ______________
Name & Signature Date
Please be advised that the above information shall only be used in relation to Deped COVID-19 internal
protocols in accordance with the Data Privacy Act.

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