(To be filled-up by parents)
Allergies: Drug/Medicine ✶
Allergies: Food ✶
Congenital Heart Defects/Heart Ailments ✶
Asthma ✶
Any implants/surgical procedure done ✶
Immunization ✶
Any previous hospitalizations? ✶
Covid-19 Vaccination:
Dates of:
Diabetes ✶
Hypertension ✶
Others: Pls. indicate