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Health History Brent International School Manila
Please complete this neatly and accurately. Brent’s Clinic keeps this Health History, as well as their form given on the first day of classes that tracks any updates.
Student’s Name: ____________________________________________________
Last First Middle
Date of Birth: _______________________________ Gender: _____________
Month Day Year
Contact person in case of emergency while enrolled at Brent:
Name Relationship to Student Phone number
______________________________ __________________ ______________________________
______________________________ __________________ ______________________________
Does your child have an illness or condition (heart condition, seizures, etc)?
Yes No If yes, explain: __________________________________________
Does your child have a suspected or diagnosed special need (ADD, autism, speech delay, etc)?
Yes No If yes, explain: __________________________________________
Does your child have any allergies (to medication, food, pets, etc)?
Yes No If yes, explain: __________________________________________
Does your child receive any medication or medical treatment, either regularly or occasionally?
Yes No If yes, explain: __________________________________________
Has your child ever been hospitalized?
Yes No If yes, explain: _________________________________________
If you know your child’s blood type, please indicate: __________ Rh group ________
A, B, AB, O + or -
If you have a family doctor in the Philippines, please provide contact information:
Doctor’s Name: ______________________________________
Work Phone: ___________________________________ Cell Phone: ____________________________
Hospital Name: _________________________________ City: __________________________________
Attach a recent passport size
photograph here
# 4 of 4
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Health History page 2
Student’s Name: __________________________________________________________
Last First Middle
If your doctor has any recommendations or restrictions regarding your child’s health, please submit documentation to Brent School. Otherwise, your child will be considered “physically fit” and expected to participate in Physical Education (P.E.) activities required by the curriculum.
Authorization
I prefer Brent’s Nurse to call before giving my child any oral medications. Yes No
I give consent for my child to receive First Aid at Brent’s Clinic.
I give consent for my child to be taken to the nearest hospital during emergency cases. In the event that my child needs emergency care and I cannot be reached, I give permission for Brent authorities to act on my behalf. I also authorize them to sign any necessary medical forms required by the hospital.
I give permission for my child to receive diagnostic procedures, emergency surgeries, and blood transfusions required by the attending physician.
________________________________ _____________________________ _________________
Parent’s Signature Parent’s Printed Name Date
