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 [ ][ ]
Diabetes Mellitus [ ][ ]
Kidney Disease [ ][ ]
Cancer [ ][ ]
Asthma [ ][ ]
Allergy [ ][ ]
Other Remarks:
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 Packs
day: per 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:
Present Health Status (pls. check) Y N Y N
Cough 2wks 1 month longer
Dizziness [ [] ] Lumps [ ][ ]
Dyspnea [ [] ] Painful urination [ ][ ]
Chest/Back pain [ [] ] Poor/loss of hearing [ ][ ]
Easy fatigability [ [] ] Syncope/fainting [ ][ ]
Joint/extremity pains [ [] ] Convulsions [ ][ ]
Blurring of vission [ [] ] Malaria [ ][ ]
Wearing eyeglasses [ [] ] Goiter [ ][ ]
Vaginal discharge/bleeding [ [] ] Anemia [ ][ ]
Dental Status: (pls. specify) Others: Pls. specify)
Present Medication taken: (pls. specify)
Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis
EXG - Electro Cardio Gram F - Full Term
Y - Yes P - Pre-mature
N - No A - Abortion
HPN - Hypertension L - Live Birth
CVD - Cardio Vascular Disease
DM - Diabetes Mellitus
Interviewed by: ___________________
Date: _______________________
]
]
]
]
]
]
]
]
]
]
]
]
CS Form 86
SHD Form 4-A
HEALTH EXAMINATION RECORD
Name: Division:
Date of Birth: Type of Work:
Civil Status:_____________ Sex:
1 Date:
Height
Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: ________Near: _________
Without glasses: Far: ________Near: _________
12 Nose:
13 Ear:
14 Hearing:
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):
