2019 SHD Form 1 Name: Date of Birth: Birthplace: Learner Reference Number (LRN): Division: Parent/Guardian: Telephone No.: Home Address: Republic of the Philippines DEPARTMENT OF EDUCATION Region ______________ Division of _____________________ ______________________________________________ School Name/ID Last First Middle SCHOOL HEALTH EXAMINATION CARD 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. Data Privacy Notice Name and Signature of Child Name and Signature of Parent I hereby authorize the Department of Education to use, collect, and process the information for the purposes of the above stated. 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. Month / Day / Year 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. Page 1
2019 SHD Form 1-A Name : ________________________________________ LRN : ______________________ 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. Date Medical History (For Learners) Name & Signature of Parent/Guardian Page 2
2019 SHD Form 1-B Name : ________________________________________ LRN : _______________________________________ 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) Deworming (√ 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 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 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 Eyes/Ears/Nose Mouth/Throat/Neck Lungs/Heart Abdomen Deformities Others, specify Examined by: Designation: LEGEND: f. Colds Note: Use Letter to record ailments and Place X if not examined Abdomen Deformities c. Severely Wasted/Underwt b. Congenital (Specify) NS f. Impetigo/boil a. Acquired (Specify) l. Others, specify Eye/Ear/Nose i. Impacted cerumen d. Inflamed pharynx c. Presence of lesions b. Enlarged tonsils a. Normal Mouth/Neck/Throat e. Pale Conjunctiva g. Eye Discharge Visiona. Normal Weight d. Ocular Misalignment a. Normal Heart/Lungs a. Normal h. Others, specify d. Murmur c. Wheeze b. Rales g. Cough e. Irregular heart rate e. Dysmenorrhea h. Severely Stunted g. Hematoma f. Matted Eyelashes e. Enlarged lymphnodes f. Others , specify Findings Grade 12/ SPED Findings Findings Grade 11/ SPED Findings Grade 10/ SPED Findings Grade 9/ SPED Grade 8/ SPED Grade 5/ SPED Grade 6/ SPED Findings Findings Findings Grade 7/ SPED Findings Grade 4/ SPED Grade 2/ SPED Findings Grade 3/ SPED Findings Kinder/ SPED Findings Grade 1/ SPED Findings Medical/Nursing Findings i. Itchiness k. Acne/Pimple j. Mucus discharge k. Nose Bleeding (Epistaxis) m. others, specify l. Capillary refill greater than 3 sec j. Skin Lessions a. Normal b. Presence of Lice c. Redness of Skin d. White SpotsAuditory i. Tall d. Overweight e. Obese f. Normal Height g. Stunted h. Bruises/ Injuries e. Flaky Skin Vision Screening using appropriate chart Vision/ Auditory Screening Skin/Scalp Skin/ Scalp Auditory Screening (Tuning Fork) a. Normal c. Eye Redness h. Ear dischrage b. Inflamed Eye Lid f. Others, Specify b. Distended c. Abdominal Pain d. Tenderness a. Passed b. Failed a. Passed b. Failed Page 3
2019 SHD Form 1-C Name : ____________________________________________ LRN : __________________________________ Medical Treatment Record Chief ComplaintDate Attended by (Name/Position) RemarksIntervention/Treatment Done Page 4
2019 SHD Form 1-D Name : ____________________________________________ LRN : __________________________________ Medical History 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 KINDER S.Y. GRADE 1 S.Y. 55 54 53 52 51 61 62 63 64 65 55 54 53 52 51 61 62 63 64 65 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 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 85 84 83 82 81 71 72 73 74 75 85 84 83 82 81 71 72 73 74 75 GRADE 2 S.Y. GRADE 3 S.Y. 55 54 53 52 51 61 62 63 64 65 55 54 53 52 51 61 62 63 64 65 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 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 85 84 83 82 81 71 72 73 74 75 85 84 83 82 81 71 72 73 74 75 LEFT PERMANENT TEETH PERMANENT TEETH TEMPORARY TEETH TEMPORARY TEETH RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT TEMPORARY TEETH TEMPORARY TEETH PERMANENT TEETH PERMANENT TEETH TEMPORARY TEETH TEMPORARY TEETH RIGHT LEFT RIGHT RIGHT LEFT RIGHT LEFT TEMPORARY TEETH TEMPORARY TEETH Guide Questions Dental Findings Yes No Remarks Page 5
2019 SHD Form 1-Da Name : ____________________________________________ LRN : __________________________________ GRADE 4 S.Y. GRADE 5 S.Y. 55 54 53 52 51 61 62 63 64 65 55 54 53 52 51 61 62 63 64 65 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 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 85 84 83 82 81 71 72 73 74 75 85 84 83 82 81 71 72 73 74 75 GRADE 6 S.Y. 1 2 3 4 5 6 7 8 9 10 11 12 55 54 53 52 51 61 62 63 64 65 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 85 84 83 82 81 71 72 73 74 75 Calculus Gingivitis Decubital ulcer Retained decidous teeth Supernumerary teeth Malocclussion Periodontal Disease ORAL HEALTH CONDITION Others, Specify Fluorosis Root fragment Cleft lip / palate Kinder RIGHT LEFT RIGHT LEFT TEMPORARY TEETH PERMANENT TEETH TEMPORARY TEETH RIGHT LEFT RIGHT LEFT RIGHT LEFT TEMPORARY TEETH TEMPORARY TEETH PERMANENT TEETH PERMANENT TEETH TEMPORARY TEETH TEMPORARY TEETH RIGHT LEFT Page 6
2019 SHD Form 1-Db Name : ____________________________________________ LRN : __________________________________ TEMPORARY TEETH PERMANENT TEETH 1 2 3 4 5 6 7 8 9 10 11 12 SYMBOL FOR MOUTH EXAMINATION - Tooth needing Oral Urgent Teatment (causing ulcer, moblie/shedding, with abscess, in pain) X - Carious tooth indicated for extraction (✓) - 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 No. T / filled Total d.f.t. For Extraction For Filling Total Sound teeth Date OUT Intervention/Treatment Done Remarks Attended by (Name/Position) 1Kinder Chief Complaint dft index Index d.f.t. 6543 KinderIndex D.M.F.T. No. T / Missing No. T. / Filled Total D.M.F.T. For Extraction For Filling Total Sound teeth No. T / decayed No. T / decayed 2 Page 7
2019 SHD Form 1-Da (extra sheet) Name : ____________________________________________ LRN : __________________________________ GRADE ___ S.Y. GRADE ___ S.Y. 55 54 53 52 51 61 62 63 64 65 55 54 53 52 51 61 62 63 64 65 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 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 85 84 83 82 81 71 72 73 74 75 85 84 83 82 81 71 72 73 74 75 GRADE ___ S.Y. GRADE ___ S.Y. 55 54 53 52 51 61 62 63 64 65 55 54 53 52 51 61 62 63 64 65 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 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 85 84 83 82 81 71 72 73 74 75 85 84 83 82 81 71 72 73 74 75 RIGHT LEFT RIGHT LEFT TEMPORARY TEETH TEMPORARY TEETH PERMANENT TEETH PERMANENT TEETH TEMPORARY TEETH TEMPORARY TEETH RIGHT LEFT RIGHT LEFT LEFT RIGHT LEFT RIGHT LEFT TEMPORARY TEETH PERMANENT TEETH TEMPORARY TEETH RIGHTTEMPORARY TEETH TEMPORARY TEETH PERMANENT TEETH RIGHT LEFT