SHD Form 4

TEACHER'S HEALTH CARD

Date:
Name: Date of Birth: Age: Gender:
School/District/Division: Civil Status
Position/Designation: Years in Service:
First Year in Service:

Family History: (pls. check) Y N Specify Relationship

Hypertension [ ][ ]
Cardiovascular Disease [ ][ ]
MONITORING TEST KIT RESULT: Diabetes Mellitus [ ][ ]
Kidney Disease [ ][ ]
Cancer [ ][ ]
RANDOM Asthma [ ][ ]
Allergy [ ][ ]
BLOOD URIC ACID CHOLESTEROL PERFORMED Other Remarks:
DATE INTERVENTION
SUGAR TEST TEST BY:
TEST Past Medical History: (check)
Y N Y N
Hypertension [ ][ ] Tuberculosis [ ] [ ]
Asthma [ ][ ] Surgical Operations (pls. specify) [ ] [ ]
Diabetes Mellitus [ ][ ] Yellowish discoloration of skin/sclera[ ] [ ]
Cardiovascular Disease [ ][ ] Last hospitalization (reason) [ ] [ ]
Allergy (pls. specify) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing: Others specify
ECG Neuropsychiatric exam:
Urinalysis Blood Typing:

Social History
Smoking Y N Age started: Sticks/packs per day:
Pack/year__________
Alcohol Y N How often: Food preference:
OB Gyn History (pls. encircle) (Female Teachers)
Menarche: Cycle Duration
Menopause: ________________
Parity: F P A L
Papsmear done: Y N if YES, When:
Self Breast examination done: Y N
Mass noted: Y N Specify where

For Male personnel: Digital rectal examination done: Y N

Date examined: _______________
Result: _______________
nurseflor23

1
 Republic of the Philippines
Department of Education
HEALTH & NUTRITION SECTION
SCHOOLS DIVISION OF MASBATE PROVINCE
2 Republic of the Philippines
ORAL HEALTH EXAMINATIONDepartment
RECORD FORof
TEACHING AND NON- TEACHING PERSONNEL
Education
BLOOD PRESSURE MONITORING HEALTH & NUTRITION SECTION
NAME:_____________________________ Age:_______
SCHOOLS DIVISION OF MASBATE PROVINCE Gender:________
Date of Birth:__________________ Marital Status:_______
BP2(after CS FORM 6
Region:________ Division:___________ School:________________________________
Signature of HEALTH EXAMINATION RECORD
30mins. Designation:_______________________________________
DATE TIME BP1 Remarks Nurse/Clinic Name:____________________________________________ Division:_________________
Rest if bp Date of Birth:____________ Sex:____ Civil Status:_____________
Teacher Medical
Date:
History:
is high) Hypertension Epilepsy Allergies
1 Height
Diabetes
Weight Bleeding disorder Others:_________________
Cardio Vascular Disease Asthma ______________
2 Temperature:
Respiratory System: Please Specify
3 Fluorography: DENTITION STATUS
STATUS Sputum Analysis:
Circulatory
18 17 System:
16 15 14 13 12 11 21 22 23 24 25 26 27 28
4 Blood Pressure:
Pulse: Sitting: Agility Test:
5 Digestive System:
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Genito-Urinary:
6STATUS
Urinalysis, etc.
7 Skin: INDEX:DMFT
8 Locomotor System:
No. of T/Decay
9 Nervous System:
10 Eyes: No. of T/Missing
Conjuctivities, etc.:
No. of T/Filled:
Color Perception:
11 Vision: TOTAL
With glasses: Far: __________ Near: _________
Without glasses: Far: __________ Near: _________
TREATMENT RECORD
12 Nose:DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST
13 Ear:
14 Hearing: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
Periodental Conditions Dental Prosthesis
19 Recommendation
Normal Signature:
Employee's Denture Wearer: Y N Remarks:_______
20 Employee's
Gingivitis Name (Print): Please Specify ____________________
Periodental
Physician's Disease
Signature: Need for Denture: Y N Remarks:_______
21 Physician's
Other Abnormal
Name Conditions
(Print): Please Specify:___________________ Remarks:_______
_________________________
Doctors Notes:
Please Specify
SYMBOL FOR MOUTH EXAMINATION
X - Carious tooth indicated for extraction JC - Jacket Crown
D - Carious tooth indicated for filling P - Pontic
RF - Root fragment RPD - Removable Partial Denture
O - Missing tooth FB - Fixed Bridge
F2 - Permanently filled tooth with CD - Complete Denture
recurrence of decay GI - Glass Ionomer
() - Sound/erupted Permanent/ SyF - Composite
Temporary tooth AgF - Amalgan
PFS - Pit and Fissure Sealant nurseflor23
nurseflor23