DEPARTMENT OF EDUCATION

REGION VII, CENTRAL VISAYAS

DIVISION OF CEBU PROVINCE
DISTRICT OF SAN FERNANDO I
SOUTH POBLACION NHS - MATH & SCIENCE SCHOOL
South Poblacion, San Fernando, Cebu

HEALTH ASSESSMENT FORM FOR LEARNERS

Name of Learner: Date of Birth: Grade Level: Age:
Name of Parent/Guardian: Contact Number:
Address:

PHYSICAL EXAMINATION
Height: Weight: Blood Type:
Farsighted ( ) Nearsighted ( )
With Glasses ( ) Without Glasses ( )

MEDICAL HISTORY - Palihug ug tubag sa mga musunod na pangutana kabahin sa panglawas sa inyong anak

YES NO REMARKS
Level of Consciousness (LOC)
Maayo/Makatubag sa pangutana (conscious and coherent)
Body Temperature
Gihilantan (febrile / Wala gihilantan (afrebile)
Head
Koto (Lice)
Lusa (Lice egg)
Kaspa (Dandruff)
Samad/nuka sa ulo (wound/skin disease)
Puno
Ug uba pa (others): _______________________________
Ear, Eyes, Nose and Throat (EENT)
Dunggan / Ear
* Magbasa/baho/boog (otitis media)
* Hubag/sakit ang dunggan (inflammation/pain)
* Naay problema sa pagdungog
Mata / Eyes
* Magpula/piskat (eye redness)
* Nagmuta (eye discharge)
* Buwinngit (stye)
* Naggamit of antipara (eyeglasses)
* Others: Please specify: _________________________
 YES NO REMARKS
Ilong / Nose
* Sip - on (colds)
* Ping - ot (Nasal Congestion)
* Sunggo / Nose Bleed
* Others: Please specify: _________________________
Totunlan / Throat
* Sakit / katol / uga (sorethroat)
Liog / Neck
Lusay likod sa dunggan og sa liog (lymph nodes at the back of
the ears and neck
Heart and Lungs
* Ubo (cough)
* Hubak (asthma)
* Lisod sa pag ginhawa (shortness of breath)
* Nag agig sakit sa kasing - kasing or may kaliwat na may
sakit sa kasing kasing
Upper Abdomen
* Sakit sa kuto - kuto (hyperacidity, abdominal pain)
* Nagkalibanga (diarrhea)
Lower Abdomen (For Females only)
* Year of First Menstruation (Menarche) ________________
* Sakit sa pus - on kung magregla (dysmenorrhea)

Parent/Guardian's Signature Over Printed Name

Date

Noted by: Evaluated by:

CRISTINE MAE B. BELEYA IVY JESSA C. GABUTIN

Class Adviser Clinic - In - Charge

Verified by:

ROCHIE G. VILLAMERO
Head Teacher III