SHD FORM 4

TEACHER’S HEALTH CARD

Date: __________________
Name: ____________________________________ Date of Birth: _______ Age: ____ Gender: __________
School – District: ______________________ Civil Status:________
Position: _____________________________ Years in Service: ____
First Year in Service: ____________________
Family History: (please check) Y N Specify Relationship
Hypertension [ ] [ ] _________________________
Cardiovascular Disease [ ] [ ] _________________________
Diabetes Mellitus [ ] [ ] _________________________
Kidney Disease [ ] [ ] _________________________
Cancer [ ] [ ] _________________________
Asthma [ ] [ ] _________________________
Allergy [ ] [ ] _________________________
Other Remarks: ____________________________________________________________________
____________________________________________________________________
Past Medical History: (check) Y N Y N
Hypertension [ ] [ ] Tuberculosis [ ] [ ]
Asthma [ ] [ ] Surgical Operations (please specify) [ ] [ ]
Diabetes Mellitus [ ] [ ] Yellowish Discoloration of skin/sclera [ ] [ ]
Cardiovascular Disease [ ] [ ] Last Hospitalization (reason) [ ] [ ]
Allergy (specify) __________________________ Others (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: _______ Per Year:____
Alcohol Y____ N____ How often: _______ Food Preference: ______________________
OB Gyn History (please 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
For Male Personnel: Digital Rectal examination done: Y____ N____ Date Examined: ____________
Result: ___________________
Present Health Status (please check) Y N Y N
Cough 2 weeks [ ] 1 month [ ] longer [ ]
Dizziness [ ] [ ] Lumps [ ] [ ]
Dyspnea [ ] [ ] Painful Urination [ ] [ ]
Chest/Back Pain [ ] [ ] Poor/Loss of Hearing [ ] [ ]
Easy fatigability [ ] [ ] Syncope/fainting [ ] [ ]
Join/Extremity pains [ ] [ ] Convulsions [ ] [ ]
Blurring of vision [ ] [ ] Malaria [ ] [ ]
Wearing Eyeglasses [ ] [ ] Goiter [ ] [ ]
Vaginal Discharge/bleeding [ ] [ ] Anemia [ ] [ ]

Dental Status: (please specify) _____________________ Others: _________________________

Present Medication Taken: (please specify) _______________________________________________
Legend: CXR – Chest X-Ray PTB – Pulmonary Tuberculosis
EXG – Electrocardiogram F – Full Term
Y – Yes P – Premature
N – No A – Abortion
HPN – Hypertension L – Live Birth
CVD – Cardiovascular Disease
DM – Diabetes Mellitus Interviewed by:________________________
Date:________________________________
SHD Form 4-A

HEALTH EXAMINATION RECORD

Name: ___________________________________ Division: __________________________________ Department: ______________________________
Date of Birth: _____________________________ Type of Work: _____________________________ Sex: _________ Civil Status: __________________

1 Date: Date: Date:

Height Height Height
Weight Weight Weight
2 Temperature:

3 Respiratory System:
Fluorogrpahy:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjunctivitis, Etc.
Color Perception:
11 Vision:
With glasses: Far: Near: With glasses: Far: Near: With glasses: Far: Near:
Without glasses: Far: Near: Without glasses: Far: Near: Without glasses: Far: Near:
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee’s Signature:
Employee’s Name (Print):
21 Physician’s Signature:
Physician’s Name (Print):
SHD – Dental TP/NTP

Region III - SDO Malolos

ORAL HEALTH EXAMINATION RECORD FOR TEACHING

AND NON-TEACHING PERSONNEL

Name: _______________________________________________________ Age: ________ Gender: _______________

Date of Birth: __________________________________________________ Marital Status: ________________________
District: ______________ School: __________________________________ Designation: __________________________

Medical History:
[ ] Hypertension [ ] Epilepsy Allergies: (please specify) _______________
[ ] Diabetes Mellitus [ ] Bleeding Disorder Others: ______________________________
[ ] Cardiovascular Disease [ ] Asthma

DENTITION STATUS

Tx DONE
CONDITION INDEX: DMFT
Number of For Extraction:
Decayed For Filling:
Number of
Missing
Number of Filled
CONDITION
Tx Done DMFT
Sound Teeth

TREATMENT RECORD

DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

Periodontal Condition Dental Prostheses

[ ] Normal Denture Wearer [ ]Y [ ]N Remarks:__________________
[ ] Gingivitis Specification: ______________________
[ ] Periodontal Disease Need for Denture [ ]Y [ ]N Remarks:__________________
Other Abnormal Conditions Specification: ______________________ __________________________
___________________________________
___________________________________

Legend: Artificial Restoration: For Treatment Done:

X – Carious / For Extraction
F – Carious / For filling
RF – Root Fragment
M – Missing Tooth
TF – Temporary Filling JC – Jacket Crown RPD – Removeable Partial Denture OP – Oral Prophylaxis
Co – Composite Restoration Ab – Abutment FPD – Fixed Partial Denture Exo – Extracted
Am – Amalgam Filling P - Pontic CD – Complete Denture AgF – Amalgam Filling
I – Inlay GIC – Glass Ionomer Cement
ZoE – Zinc Oxide Filling
R – Referred to Private Dentist
SHD – Form 3B

Republic of the Philippines

DEPARTMENT OF EDUCATION
REGION III
Division of Malolos City
SCHOOL NAME
___________________________________

DENTAL REFERRAL FORM

Patient’s Name :______________________________________ Age____________
Phone Number: _______________________________________ Gender:_________

Dear Doctor;

I am referring _________________________________________ to your office for:

[ ] Oral Prophylaxis
[ ] Restoration _________________________

[ ] Extraction _________________________

[ ] Other Procedures _________________________

_________________________

Sincerely,

_______________________________
School Dentist

--------------------------------------------------------------------------------------------------------------------------
(kindly return this slip to the school dentist)

_______________________________________

Name of Institution / Clinic

DENTAL TREATMENT SLIP

Dental Procedure done:

[ ] Oral Prophylaxis

[ ] Restoration _________________________________
[ ] Extraction __________________________________
[ ] Other Procedures ____________________________
___________________________________________
___________________________________________

Signature:
DENTIST’S NAME: _____________________
Lic. No.: ________________
Date: __________________