Clinic Sample Program
Clinic Sample Program
Region I
Schools Division Office
Vigan City
VIGAN NATIONAL HIGH SCHOOL WEST
Paratong, Vigan City
STUDENTS ID NUMBER NAME OF PATIENT/LEARNER AGE GRADE LEVEL SECTION SCHOOL YEAR
BLOOD PRESSURE
PULSE RATE
CARDIAC RATE
OXYGEN
SATURATION
MEDICAL HISTORY
DATE/TIME CHIEF COMPLAINT REMARKS
INCASE OF EMERGECNY
PARENTS NAME
ADDRESS
CONTACT NUMBER
STUDENTS ID NUMBER LEARNERS or PATIENTS NAME
2 WEST 2
HOMEROOM ADVISER
90000002
90000002
WEST 2
PATIENTS NAME AGE GRADE LEVEL SECTION SCHOOL YEAR
EST 2 16 G-10 MAYA 2019-2020
GLENDA RICOLCOL
9977048422
0 0
0 0
MBER
CLINIC INCHARGE CONTACT NUMBER
SIGNATURE CLINIC INCHARGE
1 2 3 4