JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
FICHA ENFERMERIA
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
ANTECEDENTES PERSONALES
Columna 1
Fila 1
Columna 1
Fila 1
Clear selection
Nombre Alumno
*
Your answer
Rut
*
Your answer
Edad
*
Your answer
Curso y año
*
Your answer
Fecha de nacimiento
*
MM
/
DD
/
YYYY
ANTECEDENTES DEL ALUMNO
Antecedentes del alumno
*
Hepatitis
Hipertension Arterial
Varicela
Escarlatina
Diabetes M
Sarampión
Ninguna
Alergico (a) estacionales
*
Your answer
Alergico (a) alimentarias
*
Your answer
Alergico (a) medicamentos
*
Your answer
Sufre de cólicos
*
Your answer
Su hijo (a) es celiaco
*
Your answer
Sufre de migraña, cefalea o jacqueca
*
Your answer
Tratamientos médicos permanentes
*
Your answer
Grupo sangre
*
Your answer
Plan de vacuna completo
*
Si
No
Observaciones
*
Your answer
ANTECEDENTES FAMILIARES
Nombre Madre y Teléfono
*
Your answer
Nombre Padre y Teléfono
*
Your answer
En caso de emergencia avisar a: (mencione)
*
Your answer
En caso de emergencia medica referir a: (clínica)
*
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Colegio San Francisco Javier de Huechuraba.
Report Abuse
Forms
