MEDICAL SHEET 2022 Secondary

SANTA ELIZABETH OF HUNGARY SCHOOL
SECUNDARY LEVEL
STUDENT MEDICAL RECORD

SCHOOL PERIOD 2,022
Course you enter:…………………
1.- PERSONAL DATA (Must be filled out by the father/mother or guardian) 1
Last name and name: ID No.

Place and date of birth: Age:
Home: Landline Telephone Number:
Father's name: Cell phone number:
Mother's name: Cell phone number:
Weight: Height: T/A: Blood type:
2.- HISTORY OF ILLNESSES (mark with an X , as appropriate)
Type of Disease YEAH NO

Asthma
Seizures
Diabetes
Heart disease
Kidney disease
Prolonged fever
Fractures
Nosebleed
Hepatitis
Hypertension
Mumps
Frequent dizziness
Loss of consciousness
Hearing loss
Vision problems
Rheumatism
Measles
Sinusitis
Skull Trauma
Chickenpox
Surgeries
2.1. - Indicate the type of surgery, if you had one.
2.2. - Other diseases:
3 .- OTHER MEDICAL DATA :
a) VACCINATION: COMPLETE DIAGRAM YES □ NO □

b) ALLERGIES: YES □ NO □ GUY: …………………………………………………………………………………………………….
c) PERMANENT MEDICAL TREATMENTS: YES □ NO □ Indicate which:
d) Detail any information about your child that is relevant to be taken into account for the development of the
Teaching/Learning process (Attention deficit; Learning disorders; others)2
1 Please fill out the form in clear, printed letters, without amendments, erasures or scratches.
25.- CARDIOVASCULAR EXAM ( ECG; other studies )
I certify that ……………………………………………………………………………………………., DNI N°…………………… …………………. of

……….. years of age, has been examined through corresponding Cardiovascular Studies to date. Being in the
1
Has Diagnosis from the corresponding Professional*: YES □ NO □
*In case of a positive response, please present the Diagnosis issued by the professional.
I declare that the above answers about my child's health are true and I have not omitted any information.-
Salta, ………… of ………………………………………………….. of 2.0……
Signature:…………………………………… Clarification:………………………………………………………. DNI N°………………….……..
4 .- MEDICAL EXAMINATION (to be completed by the competent professionals)
SCHOOL HEALTH CERTIFICATE
I certify that ……………………………………………………………………………………………., DNI N°…………………… …………………. of

……….. years of age, whose medical history is in my possession, has been clinically examined on the date of this
date, being in PHYSICAL CONDITION to carry out school activities typical of curricular school Physical Education,
which must correspond to his age, sex, degree of maturation and development.
Presents:
Signs or symptoms of a contagious infectious disease. YES □ NO □

Mycoses. YES □ NO □
Respiratory problems. YES □ NO □ Which is it?: ……………………………………………………………………….
Observations:
Signature and seal of the Medical Professional:…………………………………………………………. Date:

…………………………………………
ORAL HEALTH: OPHTHALMOLOGICAL EXAMINATION:
Has cavities YES NO□ □ Good vision YES NO□ □

In treatment YES NO□ □ Use glasses YES NO□ □
Good Oral Health YES □
NO
Observations:……………………………………………… ……
□ Vision Disorders YES NO
Diagnosis: ………………………………………………
□ □
Signature and seal of the Signature and seal of the Professional:……………………………………….

Professional
Date:……………………………………….. Date:……………………………………………
2
Completing this section is essential to work with the necessary curricular adaptations and the design of the student's
Institutional Pedagogical Project; doing so guarantees absolute confidentiality . It is requested to accompany with
psychodiagnosis of the corresponding professional.
Date:…………………………………………
following conditions: Able to perform Physical Education: YES - NO

Limitations: ……………………………………………………………………………………………………………………………… …………………………….
Signature and seal of the Medical Professional: ………………………………………………………….

2

MEDICAL SHEET 2022 Secondary

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MEDICAL SHEET 2022 Secondary

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SANTA ELIZABETH OF HUNGARY SCHOOL

STUDENT MEDICAL RECORD

Last name and name: ID No.

Type of Disease YEAH NO

2.1. - Indicate the type of surgery, if you had one.

2.2. - Other diseases:

3 .- OTHER MEDICAL DATA :

a) VACCINATION: COMPLETE DIAGRAM YES □ NO □

c) PERMANENT MEDICAL TREATMENTS: YES □ NO □ Indicate which:

I certify that ……………………………………………………………………………………………., DNI N°…………………… …………………. of

Salta, ………… of ………………………………………………….. of 2.0……

Signature:…………………………………… Clarification:………………………………………………………. DNI N°………………….……..

4 .- MEDICAL EXAMINATION (to be completed by the competent professionals)

SCHOOL HEALTH CERTIFICATE

I certify that ……………………………………………………………………………………………., DNI N°…………………… …………………. of

Signs or symptoms of a contagious infectious disease. YES □ NO □

Signature and seal of the Medical Professional:…………………………………………………………. Date:

ORAL HEALTH: OPHTHALMOLOGICAL EXAMINATION:

Has cavities YES NO□ □ Good vision YES NO□ □

Signature and seal of the Signature and seal of the Professional:……………………………………….

following conditions: Able to perform Physical Education: YES - NO

Signature and seal of the Medical Professional: ………………………………………………………….

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