Republic of the Philippines

Department of Education
REGION VII- CENTRAL VISAYAS
SCHOOLS DIVISION OF NEGROS ORIENTAL

NEW NORMAL HEALTH ASSESSMENT FORM FOR LEARNERS

NAME OF LEARNER: Date of Birth: Grade level:
School: Sex: Male ( ) Female ( )
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 and 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 tutonlan
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 and daghan, huot, gituslok)
ABDOMEN
Sakit sa kuto-kuto (upper abdominal pain/hyperactivity)
Nagkalibang (diarrhea)
Ug uban pa (others)
GUT (Bato/kidney)
Sakit pangihi (pain upon urination)
Gi bus-aw/sige ihi-ihi (frequent urination)
UPPER AND LOWER EXTREMITIES/ARMS & LEGS (Paa ug Bukton)
Depekto sa tiil/paa/kamot/bukton (deformity of extremities) kun 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 impeksyon na samad (infected wound)
Samad (wound), gasgas, pangus, nadisdisan, etc.
MEDICAL HISTORY
1. Naospital and bata kaniadto?
2. Unsay sakit o mga sakit na naagi an 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 iya Doctor

Assessed by: ADVISER

___________________________________ _______________________________________

HEIGHT (kg): ____________________________

WEIGHT (cm): ___________________________