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Student Medical Record College

The document is a Student Medical Record Privacy Notice/Consent form that outlines the processing and protection of personal information in compliance with the Data Privacy Act of 2012. It includes sections for personal details, medical history, family history, and authorization for medical care, requiring parental consent for various health-related actions. Parents must provide accurate information and consent for their child's medical treatment while ensuring confidentiality and data safety.

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17 views3 pages

Student Medical Record College

The document is a Student Medical Record Privacy Notice/Consent form that outlines the processing and protection of personal information in compliance with the Data Privacy Act of 2012. It includes sections for personal details, medical history, family history, and authorization for medical care, requiring parental consent for various health-related actions. Parents must provide accurate information and consent for their child's medical treatment while ensuring confidentiality and data safety.

Uploaded by

mabahosismart
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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1

STUDENT MEDICAL RECORD


PRIVACY NOTICE/CONSENT: In accordance with the Data Privacy Act of 2012 (RA 10173), LVCC School Clinic processes and secures
your personal information in accordance with its principles. As a data subject, you have the right to be informed, to correct, to
object, to delete, and to data portability. By checking the box below, you consent to the processing and disclosure of your
personal data, as well as the collection, use, disclosure, and processing of your personal data for legitimate purposes and in
accordance with our mandate. Rest assured that the data or information you share with us are safe and will be treated with the
utmost confidentiality.
( ) Agree ( ) Disagree

COURSE: YEAR LEVEL: PROGRAM HEAD:


LAST NAME FIRST NAME MIDDLE NAME ADDRESS:

AGE: GENDER: CIVIL STATUS: BIRTHDATE: PLACE OF BIRTH:

PARENT/GUARDIAN RELATIONSHIP CONTACT NO. DATE

Alternate person to contact in case of emergency:


Name: _____________________________ Contact Number: _____________ Relation to the Student: ______________
MEDICAL HISTORY
I. PAST MEDICAL HISTORY
1. Does your child have any allergies to medication, food, or others that you are aware of?
( ) None ( ) Yes, please specify

2. Does your child have any illness or disability that the school may need to be aware of?
( ) None ( ) Yes, please specify
3. Does your child receive any medication or other medical treatment either regularly or occasionally?
( ) None ( ) Yes, please specify

4. Has your child ever been hospitalized for any reason?


( ) No ( ) Yes, please specify
5. Did your child undergo any operation/surgery?
( ) No ( ) Yes, please specify
II. FAMILY HISTORY
( ) Asthma ( ) Hypertension ( ) Heart Disease ( ) Diabetes
( ) Lung Disease/PTB ( ) Liver Disease ( ) Kidney Disease Others, please specify: ________________
ADDITIONAL INFORMATION
1. Is your child on any medication?
( ) No ( ) Yes, please specify
2. Does your child need to undergo regular procedures (e.g. nebulization)
( ) No ( ) Yes, please specify
3. Do you prefer the nurse/ health care provider to call you before giving any oral
medication to your child?
( ) No ( ) Yes
* If medication can be given, please indicate what can be given for the following complaints (check YES/NO)
Illnesses Medicine YES NO
Fever Paracetamol ( ) ( )
Colds Decongestant ( ) ( )
Cough Mucolytic ( ) ( )
Asthma Salbutamol ( ) ( )
Hyperacidity Antacid ( ) ( )
Allergies Antihistamine ( ) ( )
Others: ______

* Does your child have any allergies to NSAIDS (Non-Steroidal Anti-Inflammatory Drugs)?
( ) None ( ) Yes, please specify
* Are there other health concerns that La Verdad Christian Colleges needs to be aware of?
( ) None ( ) Yes, please specify

AUTHORIZATION
I give consent for my child to receive the following:
1. Minor first aid by the nurse at the school clinic (medication and treatment) ( ) No ( ) Yes
2. Emergency care to a hospital at the school clinic/La Verdad Infirmary ( ) No ( ) Yes
3. Transportation to a hospital of the school's choosing, in severe or emergency cases ( ) No ( ) Yes

NOTE: If you checked "NO" to item numbers 1, 2, and 3, the clinic/infirmary will not provide any health care for the
student until alternate emergency care instructions from the parents/guardian are on file with the La Verdad
Christian College Clinic.

Please Note: The La Verdad Christian College Clinic will provide care for any minor medical problem, which may
occur during the school day.

OTHER REQUIREMENTS
1. In case of nebulization needs for your child: ( ) from your physician ( ) nebulization kit, submitted to the
Nurse
2. Incase of regular/emergency medication for your child: ( ) medicine, submitted to the Nurse with complete
instruction and information
3. In case of health recommendations/restrictions: ( ) medical certificate/recommendation

* Lack of the required health certificate/s indicates that your child is "PHYSICALLY FIT," thus, may be able
to participate in Physical Education (PE) activities required by the curriculum, and in other activities that
are part of the school program.

I certify that the above information is true and correct.

___________________________________ _____________
3

Name and Signature of Parent/Guardian Date

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