2019 SHD Form 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
Caraga Administrative Region
Division of Agusan del Norte
Simbalan National High School/ 304683

SCHOOL HEALTH EXAMINATION CARD

Name:
(Last Name, First Name, Middle Name)

Date of Birth: Birthplace:

Month / Day / Year
Learner Reference Number
(LRN): Division: AGUSAN DEL NORTE
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 the 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

Page 1
2019 SHD Form 1-A

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)
__ Others:

3.       Have you ever had surgery/ hospitalization? Yes No

If Yes, please identify below:

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

__ Tuberculosis
__ Cancer If yes, what kind?
__ Stroke
__ Diabetes Mellitus
__ Hypertension
__ Depression
__ Others______________________________________

5.       Exposure to cigarette/vape smoke at home? Yes No

6. Which hand is used for writing?

___ Right ___ Left ___ Both

I certify that the above information are correct.

Name & Signature of Parent/Guardian Date

Page 2
2019 SHD Form 1-B

Medical/Nursing Findings
Kinder/ Grade 1/ Grade 2/ Grade 3/ Grade 4/ Grade 5/ Grade 6/ Grade 7/ Grade 8/ Grade 9/ Grade 10/ Grade 11/ Grade 12/
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings
Date of Examination
Height (in cm)

Weight (in kg)

Nutritional Status (NS) (BMI/Wt-for-Age)

Nutritional Status (NS) (Height-for-Age)

4Ps Beneficiary (√ or X)

SBFP Beneficiary (√ or X)
Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan
Deworming (√ or X)

Iron Supplementation (√ or X)
Immunization (Specify what kind)

Menarche

Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
L R L R L R L R L R L R L R L R L R L R L R L R L R
Vision Screening using appropriate chart
L R L R L R L R L R L R L R L R L R L R L R L R L R
Auditory Screening (Tuning Fork)
Skin/ Scalp

Eyes/Ears/Nose

Mouth/Throat/Neck

Lungs/Heart
Abdomen

Deformities

Others, specify
Examined by:
Designation:
LEGEND:

NS Vision/ Auditory Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities

Screening
a. Normal Weight Vision a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
(Specify)
a. Passed b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended

c. Severely b. Failed c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain b. Congenital
Wasted/Underwt (Specify)
d. Overweight Auditory d. White Spots d. Ocular Misalignment d. Inflamed pharynx d. Murmur d. Tenderness

e. Obese a. Passed e. Flaky Skin e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart rate e. Dysmenorrhea

f. Normal Height b. Failed f. Impetigo/boil f. Matted Eyelashes f. Others , specify f. Colds f. Others, Specify

g. Stunted g. Hematoma g. Eye Discharge g. Cough

h. Severely Stunted h. Bruises/ Injuries h. Ear dischrage h. Others, specify

i. Tall i. Itchiness i. Impacted cerumen

j. Skin Lessions j. Mucus discharge

k. Acne/Pimple k. Nose Bleeding

(Epistaxis)
l. Capillary refill l. Others, specify
greater than 3 sec
m. others, specify

Note: Use Letter to record ailments and Place X if not examined

Page 3
2019 SHD Form 1-C

Medical Treatment Record

Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)

Page 4
2019 SHD Form 1-D

Dental Findings

Medical History Guide Questions

Yes No Remarks Do you have a toothbrush? Y N

Allergy How many times do you brush your teeth?

Asthma How many times do you change your toothbrush in a year?

Anemia Do you use toothpaste in brushing?

Bleeding problem How many times do you visit the dentist in a year?

Heart Ailment

Hypertension
Diabetes

Epilepsy

Kidney Disease

Convulsion
Fainting

GRADE 7 S.Y. GRADE 8 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 9 S.Y. GRADE 10 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

Page 5
2019 SHD Form 1-Db

TEMPORARY TEETH dft index PERMANENT TEETH

1 2 3 4 5 6
Index d.f.t. Kinder 1 2 3 4 5 6 Index D.M.F.T. Kinder 7 8 9 10 11 12

No. T / decayed No. T / decayed

No. T / filled No. T / Missing

Total d.f.t. No. T. / Filled

For Extraction Total D.M.F.T.

For Filling For Extraction

Total Sound teeth For Filling

Total Sound teeth

SYMBOL FOR MOUTH EXAMINATION

OUT - Tooth needing Oral Urgent Teatment
(causing ulcer, moblie/shedding, with abscess, in pain)

X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent/Temporary tooth FB - Fixed Bridge
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant CD - Complete Denture
RF - Root fragment JC - Jacket Crown GI - Glass Ionomer
M - Missing tooth P - Pontic SyF - Composite

F2 - Permanently filled tooth with RPD - Removable Partial Denture AgF - Amalgan
recurrence of decay UE - Unerupted teeth
rtt - Retained temporary teeth indictaed - Erupting lower tooth
for extraction - Erupting upper tooth
Intervention/Treatment Record

Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)