2019 SHD Form 1
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region V – Bicol
Division of Camarines Norte
IGNACIO ESPAÑOL ELEMENTARY SCHOOL / 112251
SCHOOL HEALTH EXAMINATION CARD
Name:
Last First Middle
Date of Birth: Birthplace:
Month/Day/Year
Learner Reference Number (LRN): Division:
Parent/Guardian: Jenny Raga Telephone No.
Home Address:
Data Privacy Notice
The Department of Education shall engage in the collection of health / medical information
for the purpose 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.
This information shall be stored and held confidentially in accordance with the provision 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.
For inquiries, requests and concerns regarding data privacy rights, please contact the data
privacy compliance officer, team of the school, Schools division office or regional office
concerned.
I hereby authorized the Department of Education to use, collect, and process the
information for the purpose of the above stated.
________________________________ ________________________________
Name and Signature of Child Name and Signature of Parent/Guardian
/fylp
2019 SHD Form 1-A
Name : __________________________________________________ LRN: __________________
Medical History (For Learners)
1. Do you have any allergies? _____ Yes _____ No
If yes, please specify below:
_____ Medicine
_____ Pollens
_____ Food
_____ Stinging Insects
_____ Others ________________________________________________________________
2. Do you have any ongoing medical condition? _____ Yes _____ No
If yes, please specify 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 specify below:
_________________________________________________________________________
4. Does anyone in your family have the following conditions?
_____ Tuberculosis
_____ Cancer
_____ 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.
_________________________________________ ________________________
Name and Signature of Parent/Guardian Date
Page 2
2019 SHD Form 1-B
Name: _______________________________________________ LRN: ___________________
Medical/Nursing Findings
Kinder/ Grade 1/ Grade 2/ Grade 3/ Grade 4/ Grade 5/ Grade 6/ Grade 7/ Grade 8/ Grade 9/ Grade 10/ Grade 11/ Grade 12/
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED
Findings
Findings
Findings
Findings
Findings
Findings
Findings
Findings
Findings
Findings
Findings
Findings
Findings
Date of Examination
Height (in cm)
Weight (in kg)
Nutritional Status (NS) (BMI/WT-for-Age)
Nutritional Status (NS) (Height-for-Age)
4P’s Beneficiary ( / or x)
SBFP Beneficiary ( / 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
Deworming ( / or x)
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
Vision Screening using appropriate chart
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
Auditory Screening (tuning Fork)
Skin/Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen
Deformities
Others, specify
Examined by:
Designation:
LEGEND:
Vision/
NS Auditory Skin/Scalp Eye/Ear/Nose Mouth/Throat/Neck Heart/Lungs Abdomen Deformities
Screening
a. Normal Weight Vision a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
(Specify)
b. Wasted a. Passed b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended
c. Severely
Wasted/Underwt b. Failed c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal pain b. Congenital
d. Ocular (Specify)
d. Overweight Auditory d. White Spots Misalignment d. Inflamed pharynx d. Murmur d. Tenderness
e. Enlarged e. Irregular heart
e. Obese a. Passed e. Flaky Skin e. Pale Conjunctive lymphnodes rate e. Dysmenorrhea
f. Matted
f. Normal Height b. Failed f. Impetigo/Boil Eyelashes f. Others, specify f. Colds f. others, specify
g. Stunned g. Hematoma g. Eye Discharge g. Cough
h. Severely
Stunned h. Bruises/Injuries h. Ear Discharge h. Others, specify
i. Inpacted
i. Tall i. Itchiness cerumen
j. Skin Lesions j. Mucus discharge
k. Acne/Pimple k. Nose bleeding
l. Capillary refill
greater than 3 sec l. other, specify
m. others, specify
Page 3 /fylp
2019 SHD Form 1-C
Name: _______________________________________________ LRN: ______________________
Medical Treatment Record
Date Chief Complaints Intervention/Treatment Remarks Attended by:
Done (name/Position)
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