Republic of the Philippines

Department of Education
Region VII – Central Visayas
CEBU PROVINCE DIVISION
NEW NORMAL HEALTH ASSESSMENT FORM FOR LEARNERS

Name of Learner: Date of Birth: Grade Level:

School: District:

Name of Parent/ Guardian: Contact Number (telephone/ cell no.):

Home Address:
Instruction: Palihug ug tubag sa mga musunod na pangutana kabahin sa panglawas sa inyong mga anak
General Assessment
YES NO REMARKS
LEVEL OF CONSCIOUSNESS(LOC)
Maayo/makatubag sa pangutana (conscious and coherent)
BODY TEMPERATURE
Gihilantan (febrile)
HEAD
Koto (lice)
Lusa (lice egg)
Kaspa (dandruff)
Samad/nuka sa ulo (wound/skin disease)
Puno
Ug uban pa (others)
EENT (Dunggan/Ears)
Magbasa/baho/boog (otitis media)
Hubag/sakit ang dunggan (inflammation/pain)
EENT (Mata/Eyes)
Magpula/piskat (eye redness)
Nagmuta-muta (eye discharges)
Buwinggit (stye)
Luspad ang conjunctiva (pale conjunctiva)
Naggamit ug antipara (eyeglasses)
Ug uban pa (others)
EENT (Nose/Ilong)
Sip-on (colds)
Ping-ot (nasal congestion)
Ug uban pa (others)
EENT (Totunlan/Throat)
Sakit/ katol/uga (sorethroat), uga ang totunlan
EENT (Liog/Neck)
Lusay likod sa dunggan ug sa liog (lymph nodes at the back of the ears and neck)
HEART AND LUNGS
Ubo (cough)
Hubak (asthma)
Lisod pag ginhawa (shortness of breath)
Nag agig sakit sa kasing-kasing/may kaliwat na may sakit sa kasing-kasing (kuba ang
dughan, huot, gituslok)
ABDOMEN
Sakit sa kuto-kuto (upper abdominal pain/hyperacidity)
Nagkalibanga (diarrhea)
Ug uban pa (others)
GUT (PUS-ON/ LOWER ABDOMEN (Para Sa Mga Babaye Lamang)
Kanus-a unag gidugo (menarche)___________________ isulat ang tuig (ex. 2019)
Sakit ang pus-on kung nag regla (dysmenorrhea)
GUT (Bato/ Kidney)
Sakit inig pangihi (pain upon urination)
Gibus-aw/sige ihi-ihi (frequent urination)
UPPER AND LOWER EXTREMITIES/ ARMS AND LEGS (Paa ug Bukton)
Depekto sa tiil/paa/kamot/bukton (deformity of extremeties) kung naa isulat
unsa_____________________________________
SKIN (Panit)
may nanurok (rashes)
Katol-katol ( pruritus)
Ap-ap/puti-puti sa panit (white spots)
Bun-i (ringworm)
Konggo (warts)
Hubag (boil)
Bugas (acne)
Kurikong ( scabies)
Bungag singot (prickly heat)
Na inpeksyon na samad (infected wound)
Samad (wound), gasgas, pangus, nadisdisan, etc.
MEDICAL HISTORY:
1. Naospital ang bata kaniadto?
2. Unsay sakit o mga sakit na naagian sa bata? Kung duna, palihug ug sulat
3. May namatikdan nga allergy sa pagkaon/ tambal ug uban pa?
4. Kumpleto ba siya sa bakuna?
5. Kinsay iyang Doctor?

_____________________________________________
Name of Parent

Verified by: _____________________________________________ ___________________________________________

NURSE II ADVISER