2019 SHD Form 1
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IX, Zamboanga Peninsula
Division of Zamboanga del Sur
______________________________________________
School Name/ID
SCHOOL HEALTH EXAMINATION CARD
Name:
Last First Middle
Date of Birth: Birthplace:
MM/DD/YYYY
Learner Reference Number (LRN): Division: Zamboanga del Sur
Parent/Guardian: Mobile No.:
Home Address:
Data Privacy Notice
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.
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.
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.
I hereby authorize the Department of Education to use, collect, and process the information for the
purposes of the above stated.
Ang DepEd ay mangongolekta ng impormasyong pangkalusugan/medikal para sa mga layunin ng
pagsubaybay, pagbibigay ng kinakailangang mga interbensyon sa kalusugan/medikal, at mga layuning pang-
edukasyon. Ang impormasyong ito ay ipoproseso alinsunod sa mga probisyon ng Data Privacy Act at ng Data
Privacy Policy ng DepEd.
Ang impormasyong ito ay mananatiling kumpidensyal alinsunod sa mga probisyon ng Basic Education Act
at maaari lamang ibahagi sa ibang mga ahensya ng gobyerno o mga ikatlong partido na napapailalim sa Data
Sharing Agreement at mga kinakailangan sa privacy ng data para sa mga lehitimong layunin lamang.
Para sa mga katanungan, kahilingan, at alalahanin tungkol sa iyong mga karapatan sa privacy ng data,
mangyaring makipag-ugnayan sa data privacy compliance officer, team ng paaralan, schools division office, o
regional office na kinauukulan.
Sa pamamagitan nito, pinahihintulutan ko ang DepEd na gamitin, kolektahin, at iproseso ang
impormasyon para sa mga layunin ng nakasaad sa itaas.
______________________________ ____________________________
Name and Signature of Child Name and Signature of Parent
Page 1
2019 SHD Form 1-A
Name: ________________________________________ LRN: ______________________
Medical History (For Learners)
1. Do you have any allergies? Yes No
If Yes, please identify below:
_____ Medicine _____ Stinging Insects
_____ Pollens _____ Others:
_____ Food
2. Do you have any ongoing medical condition? Yes No
If Yes, please identify below:
_____ Error of refraction _____ Cancer
_____ Asthma _____ Diabetes Mellitus
_____ Anemia _____ Hypertension
_____ Bleeding disorder _____ COPD/Emphysema/Bronchitis
_____ Hernia (painful bulge in the groin area) _____ Seizure
_____ Others: _________________________ _____ Heart problem
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 _____ Hypertension
_____ Cancer If yes, what kind? _____ Depression
_____ Stroke _____ Others:
_____ Diabetes Mellitus
5. History of smoking/vaping? Yes No
if Yes, No. of years No. of cigarettes per day:
6. Exposure to cigarette/vape smoke at home? Yes No
7. Which hand is used for writing? ___ Right ___ Left ___ Both
8. Blood Type:
9. Immunization History
Vaccines: Last dose given
No. doses received Date Location
_____ BCG
_____ Hep B
_____ Pentavalent vaccine (DPT-HiB-HepB)
_____ IPV
_____ OPV
_____ PCV
_____ MMR
_____ Rotavirus
_____ Inactivated Influenza(annual)
_____ Hepatitis A
_____ Varicella
_____ Typhoid
_____ Japanese Encephalitis
_____ Menigococcal
_____ MrTD
_____ HPV
_____ COVID-19
_____ Others (please specify):
Name & Signature of Parent/Guardian Date
Page 2
2019 SHD Form 1-B
Name : _____________________________________________________________ LRN : ___________________________________
Last First Middle
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)
4Ps 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/ Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities
Screening
Vision a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
a. Normal Weight
(Specify)
b. Wasted/ a. Passed b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended [Link]
Underwt (Specify)
c. Severely b. Failed c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain
Wasted/Underwt
d. Overweight Auditory d. White Spots d. Ocular d. Inflamed pharynx d. Murmur d. Tenderness
Misalignment
e. Obese a. Passed e. Flaky Skin e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart e. Dysmenorrhea
rate
f. Normal Height b. Failed f. Impetigo/boil f. Others , specify f. Others, Specify
f. Matted Eyelashes f. Colds
g. Stunted g. Hematoma g. Eye Discharge g. Cough
h. Severely h. Bruises/ Injuries h. Ear dischrage h. Others, specify
Stunted
i. Tall i. Itchiness
i. Impacted cerumen
j. Skin Lessions j. Mucus discharge
k. Acne/Pimple k. Nose Bleeding
(Epistaxis)
l. Capillary refill greater l. Others, specify
than 3 sec
m. others, specify
Note: Use Letter to record ailments and Place X if not examined
Page 3
2019 SHD Form 1
Name : ____________________________________________ LRN : __________________________________
Medical Treatment Record
Intervention/
Attended by
Date Chief Complaint Remarks
(Name/Position)
Treatment Done
Page 4
Name: LRN:
SCHOOL ORAL HEALTH EXAMINATION CARD
KINDER S.Y. GRADE 1 S.Y.
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH TEMPORARY TEETH
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
PERMANENT TEETH
PERMANENT TEETH
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
TEMPORARY TEETH TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
GRADE 2 S.Y. GRADE 3 S.Y.
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH TEMPORARY TEETH
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
PERMANENT TEETH
PERMANENT TEETH
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
TEMPORARY TEETH TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
GRADE 4 S.Y. GRADE 5 S.Y.
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH TEMPORARY TEETH
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 ###
PERMANENT TEETH
PERMANENT TEETH
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 ###
TEMPORARY TEETH TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
Name: LRN:
GRADE ____ S.Y. ORAL HEALTH CONDITION
Kinder 1 2 3 4 5 6
7 8 9 10 11 12
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Gingivitis
TEMPORARY TEETH Periodontal Disease
Malocclussion
Supernumerary teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Retained decidous teeth
PERMANENT TEETH
Decubital ulcer
Calculus
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Cleft lip / palate
Root fragment
Fluorosis
TEMPORARY TEETH Others, Specify
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
TEMPORARY TEETH dft index PERMANENT TEETH
1 2 3 4 5 6
Index d.f.t. Kinder 1 2 3 4 5 6 Index D.M.F.T. Kinder 7 8 9 10 11 12
No. T / decayed No. T / decayed
No. T / filled No. T / Missing
Total d.f.t. No. T. / Filled
For Extraction Total D.M.F.T.
For Filling For Extraction
Total Sound teeth For Filling
Total Sound teeth
SYMBOL FOR MOUTH EXAMINATION
X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent 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 CO - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AM - Amalgan
recurrence of decay
INTERVENTION/TREATMENT RECORD
Attended by
Date Chief Complaint Intervention/Treatment Done Remarks
(Name/Position)
