2018 SHD Form 4

Republic of the Philippines

Department of Education
Region _______________________
Schools Division of ____________________

ANNUAL HEALTH SERVICES ACCOMPLISHMENT REPORT

SY: ________________________

Region Division:

Total No. of Elem. Schools Visited

Total No. of Sec. Schools Visited

I. General Information
A. School Enrolment
1. Male
2. Female
B. No. of School Personnel
1. Teaching
Male
Female
2. Non-Teaching
Male
Female
II. Health Services
A. Health Appraisal
1. No. of Assessed:
a. Learners
b. Teachers
c. Non-Teaching Personnel
2. No. with Health Problems
a. Learners
b. Teachers
c. Non-Teaching Personnel
3. No. of Vision Screening (Learners)
B. Treatment Done
1. Learners
2. Teachers
3. Non-Teaching Personnel
2018 SHD Form 4

C. No. Of Learners Dewormed

1. 1st Round
2. 2nd Round
D. No. of Learners Given Iron Supplement
E. No. of Learners Immunized (Specify vaccine given)
F. No. of consultation attended
1. Learners
2. Teachers
3. Non-Teaching Personnel
G. Referral (No. Referred to)
1. Physicians
2. Dentists
3. Guidance Counselors
4. Other health facilities
5. RHU/ District/ Provincial Hospital
III. Health Education
No. of Classes given health lectures:
A. No. of orientation training conducted to:
1. Learners
2. Teachers
3. Parents
4. Others (Specify)
B. No. of conferences/meeting with:
1. Teachers/ Adminstrators
2. Health officials
3. Learners
4. Parents
5. LGU/Barangay
6. NGOs/Stakeholders
C. Involvement as Resource Person/ Consultant/ Adviser/ Judge
1. Health Activities/ programs/ contests
2. Class Discussion
3. Health Clubs/ Organization
IV. School-Community Activities for Health and Nutrition
A. PTA/ Homeroom Organization Meetings
B. Parent Education Seminar/ Workshop/Training
C. Home Visits Conducted
D. Hospital Visits Made
2018 SHD Form 4

V. Common Signs & Symptoms

A. Skin and Scalp
1. Presence of Lice (Pediculosis)
2. Redness of Skin
3. White Spots
4. Flaky Skin
5. Minor Injuries
6. Impetigo/Boil
7. Skin Lesions
8. Acne/Pimples
9. Itchiness
B. Eye and Ears
1. Matted eye lashes
2. Eye redness
3. Ocular misalignment (Squint)
4. Eye dischrge
5. Pale conjunctiva
6. Stye
7. Ear discharge
8. Mucos discharge
9. Nose bleeding (epistaxis)
C. Mouth/ Neck / Throat
1. Presence of lessions
2. Inflammed pharynx
3. Enlarged tonsils
4. Enlarged lymphnodes
D. Heart and Lungs
1. Rales
2. Murmur
3. Irregular heart rate
4. Wheezes
E. Deformities
1. Acquired (Specify)
2. Congenital (Specify)
2018 SHD Form 4

F. Nutritional Status
a. Normal
b. Wasted/Underweight
c. Severely Wasted/Underweight
d. Overweight
e. Obese
f. Normal Height
g. Severely Stunted
h. Stunted
i. Tall
G. Abdomen
1. Abdominal pain
2. Distended
3. Tenderness
4. Dysmenorrhea
H. Other Signs & Symptoms Noted:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I. List of Diagnosed Diseases (as reported by Medical Doctors)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
2018 SHD Form 4

J. Dental Service
1. Gingivitis
2. Periodontal Disease
3. Malocclussion
4. Supernumerary teeth
5. Retained decidous teeth
6. Decubital ulcer
7. Calculus
8. Cleft Lip/ Palate
9. Flourosis
10. Others / Specify
11. Total # of DMFT
12. Total # of dmft
VI. Remarks:

Prepared by: Noted by:

Name / Designation School Head/ SDS/RD

(To be accomplished by the School Nurse, then to be consolidated
at the SDO & RO levels, and for submission to BLSS-SHD) Date