SHD Form 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
Caraga Administrative Region
Division of Agusan del Sur

SCHOOL HEALTH EXAMINATION CARD

Name: _________________________________________________________________
Last First Middle
Date of Birth: ________________________ Birthplace: _____________________________
Month/Day/Year
School ID: _____________ Region: _______________________________
Learner Reference Number (LRN): _____________________ Division: ____________________
Parent/Guardian: ___________________________________ Telephone No.: ______________
Home Address: ________________________________________________________________

Data Privacy Notice

The Department of Education shall engage in the collection of health / medical information for the
purposes of tracking, provision of necessary health/medical interventions, and educational purposes. This
information shall be processed in accordance with the provisions of the Data Privacy Act and the Data
Privacy Policies of the Department.
This information shall be stored and held confidentially in accordance with the provisions of the
Basic Education Act and may only be shared with other government agencies or third parties subject to
Data sharing agreements and data privacy requirements for legitimate purposes only.
For inquiries, requests and concerns regarding your data privacy rights, please contact the data
privacy compliance officer, team of school, schools division office or regional office concerned.
I hereby authorize the Department of Education to use, collect, and process the information for the
purposes of the above stated.

___________________________ ____________________________
Name and Signature of Child Name and Signature of Parent
SHD Form 1-A
Name : _______________________________________ LRN:
_________________________
Medical History (For Learners)
1. Do you have any allergies? _____YES _____NO
If Yes, please identify below:
______ Medicine
______ Pollens
______ Food
______ Stinging Insects
______ Others: ____________________________________

2. Do you have any ongoing medical condition? ______ YES _____NO

If Yes, please identify below:
______ Error of refraction
______ Asthma
______ Seizure
______ Heart problem
______ Anemia
______ Bleeding disorder
______ Hernia (painful bulge in the groin area)
______ Other: _______________________________________
3. Have you ever had surgery/hospitalization? ________ YES _______ NO
If Yes, please identify below:

_________________________________________________________________

4. Does anyone in your family have the following condition:

______ Tuberculosis
______ Cancer
______ Stroke
______ Diabetes Mellitus
______ Hypertension
______ Depression
______ Other _____________________________________

5. Exposure to cigarette/vape smoke at home? ______ YES ______ NO

I CERTIFY THAT ABOVE INFORMATION ARE CORRECT.

_________________________________________ __________________
Name & Signature of Parent/Guardian DATE

SHD Form 1-C

Name : ______________________________ LRN : ________________________

Medical Treatment Record

Date Chief Complaint Inventory/Treatment Remarks Attended by

Done (Name/Position)