Republic of the Philippines

Department of Education
Region VI – Western Visayas
SCHOOLS DIVISION OF ROXAS CITY
City of Roxas

SCHOOL HEALTH EXAMINATION CARD

Junior HighPupils
Elementary School
NAME: SCHOOL
Last First Middle

Date of Birth Region

Month Day Year

Birthplace Division
Parent/Guardian Telephone No.
Address
Pre-Elem
Grade 7 Grade81
Grade Grade92
Grade Grade103
Grade Grade 4 Grade S Grade 6

Intervention

Intervention

Intervention
Intervention

Intervention

Intervention

Intervention
Finding

Finding

Finding

Finding

Finding
Finding

Finding

Date of Examination
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Height
Weight
Nutritional Status (NS)
Visual Acuity (Snellen's)
a. N Rt, b. N Lf, c. AbN Rt, d. AbN Lf
Hearing (Tuning Fork)
a. N RI, b. N Lf, o. AbN Rt, d. AbN Lf
Skin/Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen/Genitalia
Spine/Extremities
Others, specify
Examined by

Skin/6calp Eyes/Ear/Nose Mouth/Neck/Throat Lungs/Hea rt Abdomen/ Spine/ Remarks/

Genitalia Extremities Intervention
a. Normal a. Normal a. Normal eye a. Normal Mouth a. Normal lungs a Normal a. Normal a. Needs
Abdomen Spine Supervision
b. Below b. Pediculosis b. Normal ears b. Normal Throat b. Normal heart b Normal b. N. Upper b. Needs close
Normal Genitalia Extremities supervision
c. Above c. Tinea Flava c. Normal nose Enlarged Tonsils
C c. Raies c. Mass c. N. Lower c. Needs
Normal with/w/o exudates Extremities follow-up
d. Ringworm d. Squinting d. Lip lesion d. Wheeze d. Hemorrhoids d. Scoliosis d. Corrected
e. Eczema e. Pale e. Inflamed pharynx e. Murmur e. Tenderness e. Lordosis e. Treated
Conjunctiva with/w/o exudates
f. lmpetigo/ f. Ear discharge f. Enlarged lymph f. Deformed f. Genital f. Kyphosis f. Advised/
boil nodes Chest Discharge counseled
g. Hematoma g. Impacted g. Enlarged thyroid g. Distant heart g. Hernia g. Bowlegs/ g. Referred
cerumen gland sounds knock knees
h. Bruises h. Septal h. Speech defect h. Irregular h. Others, h. Flat foot h. Parents
deviation heart rate specify notified
i. Cuts/ i. Nasal i. Dental problem ' Others, i. Club foot i. Others,
Lacerations discharge specify specify
j. Allergy j. Others, j. Others, specify j. Others,
specify specify
k. Others,
specify
 Republic of the Philippines
Department of Education
Region VI – Western
SCHOOLS DIVISION
VisayasOF ROXAS CITY
City of Roxas

SCHOOL HEALTH EXAMINATION CARD

Junior HighPupils
Elementary School

MEDICAL HISTORY
YES NO Guide Questions
Allergy
Asthma Do you have a toothbrush? Y N
Anemia How many times do you brush your teeth? Once 2x 3x
Bleeding Problem
Heart ailment How many times do you change your toothbrush in a year?
Diabetes
Epilepsy Do you use toothpaste in brushing? Y N
Kidney disease How many times do you visit the dentist in a year? once 2x
Convulsion
Fainting
ORAL HEALTH CONDITION
CONDITION AND TREATMENT NEEDS 7
Pre-SchooIer 18 92 10
3 4 5 6
CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
Periodontal Disease
TEMPORARYTE ETH H U XOA
Malocclusion
Supermumentary
tooth
Retained deciducous
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
tooth
Decubital Ulcer

48 47 46 45 44. 43 42 41 31 32 33 34 35 36 37 38
Gleh lip/palate
CONDITION
TREATMENT Root fragment
NEEDS
Fluorosis
TEMPORARY TEETH

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

CONDITION

TEMPORARY TEETH DATE OF VISITS

DENTAL PROCEDURES
Index: d. f. t Pre-schoole
7 81 92 103 4 5 6
Pre-schooler
7 1
8 29 3
10 4 5 6 Remarks No. T/decayed
DATE No. T/filled
Examination Total d.f.t.
Sealant (G.I.)
Gum Treatment PERMANENT TEE TH DATE OF VISIT S
Permanent filling
Index: D.M.F.T. Pre-schooled
7 81 92 10
3 4 5 6
ART
No. T/decayed
Extraction
No. T/Missing
Oral prophylaxis
No. T/filled
Referral
Total D.M.F.T.
Other oral treatment
Total Sound Teeth