2019 SHD Form 4

TEACHER'S HEALTH CARD

Date: April 10, 2020
Name: JONATHAN A. SUMALINOG Date of Birth: JAN. 16, 1995 Age: 25 Gender: M
School/District/Division: PLACER NHS- PLACER DISTRICT I, SURIGAO DEL NORTE DIVISION Civil Status SINGLE
Position/Designation: TEACHER II Years in Service: 3
First Year in Service: Jun-17

Family History: (pls. check) Y N Specify Relationship

Hypertension [ ] [ / ]
Cardiovascular Disease [ ] [ / ]
Diabetes Mellitus [ ] [ / ]
Kidney Disease [ ] [ / ]
Cancer [ ] [ / ]
Asthma [ ] [ / ]
Allergy [ ] [ / ]
Other Remarks:

Past Medical History: (check)

Y N Y N
Hypertension [ ] [ / ] Tuberculosis [ ] [ / ]
Asthma [ ] [ / ] Surgical Operations (pls. specify) [ ] [ / ]
Diabetes Mellitus [ ] [ / ] Yellowish discoloration of skin/sclera [ ] [ / ]
Cardiovascular Disease [ ] [ / ] Last hospitalization (reason) [ ] [ / ]
Allergy (pls. specify) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing: Others specify
ECG Neuropsychiatric exam:
Urinalysis Blood Typing: O+

Social History
Smoking Y N X Age started: Sticks/packs per day: Packs per year:
Alcohol Y N X How often: Food preference:

OB Gyn History (pls. encircle) (Female Teachers)

Menarche: Cycle Duration
Menopause: ________________
Parity: F P A L
Papsmear done: Y N if YES, When:
Self Breast examination done: Y N
Mass noted: Y N Specify where
For Male personnel: Digital rectal examination done: Y N Date examined:
Result:

Present Health Status (pls. check) Y N Y N

Cough 2wks 1 month longer
Dizziness [ ][ / ] Lumps [ ] [ / ]
Dyspnea [ ][ / ] Painful urination [ ] [ / ]
Chest/Back pain [ ][ / ] Poor/loss of hearing [ ] [ / ]
Easy fatigability [ ][ / ] Syncope/fainting [ ] [ / ]
Joint/extremity pains [ ][ / ] Convulsions [ ] [ / ]
Blurring of vision [ ][ / ] Malaria [ ] [ / ]
Wearing eyeglasses [ ][ / ] Goiter [ ] [ / ]
Vaginal discharge/bleeding [ ][ / ] Anemia [ ] [ / ]
Dental Status: (pls. specify) Others: Pls. specify)
Present Medication taken: (pls. specify)
Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis
EXG - Electro Cardio Gram F - Full Term
Y - Yes P - Pre-mature
N - No A - Abortion
HPN - Hypertension L - Live Birth
CVD - Cardio Vascular Disease
DM - Diabetes Mellitus Interviewed by:

Date:
CS Form 86

2019 SHD Form 4-A

HEALTH EXAMINATION RECORD
Name: JONATHAN A. SUMALINOG Division: SURIGAO DEL NORTE Department: DEPED
Date of Birth: JANUARY 16, 1995 Type of Work: TEACHING Sex: MALE Civil Status: SINGLE

1 Date: Date: Date:

Height Height Height
Weight Weight Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: __________ Near: _________ With glasses: Far: __________ Near: _________ With glasses: Far: __________ Near: _________
Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee's Signature:
Employee's Name (Print):
21 Physician's Signature:
Physician's Name (Print):
2019 SHD Form 4-B
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region ______________
Division of _____________________

DISTRICT
______________________________________________
School Name/ID

ORAL HEALTH PROFILE OF TEACHING AND NON-TEACHING PERSONNEL

Number of Teachers Number of Teeth

Gum Condition Denture Wearer Need for Denture

Schools No. of Oral With

Teachers Examination Defects Caries Free Periodontal Complete
Removable
Complete
Removable D M F
Sound
Normal Gingivitis Partial Partial Teeth
Disease Denture Denture Denture Denture

Submitted by: Approved by:

School Dentist
Schools Division Superintendent