2018 SHD Form 2
REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION
Pasig City
SCHOOL HEALTH EXAMINATION CARD
Name: School ID:
Last First Middle
LRN:
Date of Birth: Region: MIMAROPA
Month Day Year
Birthplace: Division: SCHOOLS DIVISION OF PALAWAN
Parent/Guardian: Telephone No.:
Address:
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
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Height (in cm)
Weight (in kg)
Nutritional Status (NS) (BMI/Wt-for-Age)
Nutritional Status (NS) (Height-for-Age)
Vision Screening using appropriate chart
Auditory Screening (Tuning Fork)
Skin/ Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen
Deformities
Iron Supplementation (√ or X)
Deworming (√ or X)
Immunization (Specify what kind)
SBFP Beneficiary (√ or X)
4Ps Beneficiary (√ or X)
Menarche (√ the Start)
Others, specify
Examined by:
LEGEND:
Vision/ Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Lungs/Heart Abdomen Deformities
Screening
a. Normal a. Passed a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
Weight
b. Wasted/ b. Failed b. Presence of Lice b. Inflammed Eyelid b. Enlarged tonsils b. Rales b. Distended b. Congenital
Underweight (Specify)
c. Severely c. Redness of Skin c. Eye Redness c. Presence of lesions d. Wheeze c. Abdominal Pain
Wasted/Underwt
d. Overweight d. White Spots d. Ocular Misalignment d. Inflamed pharynx e. Murmur d. Tenderness
e. Obese e. Flaky Skin E. Pale Conjunctiva e. Enlarged lymphnodes h. Irregular heart rate e. Dysmenorrhea
f. Normal Height f. Impetigo/ f. Ear discharge f. Others , specify i. Others, f. Others, Specify
boil specify
g. Stunted g. Hematoma g. Impacted cerumen
h. Severely h. Bruises/ Injuries h. Mucus discharge
Stunted
i. Tall i. Itchiness i. Nose Bleeding
(Epistaxis)
j. Skin Lessions j. Eye dischrage
k. Acne/Pimple k. Matted Eyelashes
l. Others , specify
Note: Use Letter to record ailments and Place X if not examined
2018 SHD Form 2
INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)
SCHOOL ORAL HEALTH EXAMINATION CARD
Medical History Guide Questions
Yes No Remarks 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?
Health Ailment
Diabetes
Epilepsy
Kidney Disease
Convulsion
Fainting
KINDER S.Y. GRADE 1 / 7 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
2
2018 SHD Form 2
Name:
GRADE 2/8 S.Y. GRADE 3/9 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 4/10 S.Y. GRADE 5/11 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 6/12 S.Y. ORAL HEALTH CONDITION
1 2 3 4 5 6
Kinder 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
3
2018 SHD Form 2
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/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
O - Missing tooth P - Pontic SyF - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AgF - Amalgan
recurrence of decay
INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)
Mouth Examination Done
Mouth Examination Done
Mouth Examination Done
Mouth Examination Done
Mouth Examination Done
Mouth Examination Done
Mouth Examination Done
Appendix 8
HNC NS Form 3
Republic of the Philippines
Department of Education
Region _______________________
Division of ____________________
ANNUAL HEALTH SERVICES ACCOMPLISHMENT REPORT
SY: ________________________
Name of School: School ID No.:
Total No. of Elem. Schools Visited
Total No. of Sec. Schools Visited
I. General Information
A. School Enrolment
1. Male
2. Female
B. No. of School Personnel
1. Teaching
Male
Female
2. Non-Teaching
Male
Female
II. Health Services
A. Health Appraisal
1. No. of Assessed:
a. Learners
b. Teachers
c. NTP
2. No. with Health Problems
a. Learners
b. Teachers
c. NTP
3. No. of Vision Screening (Learners)
B. Treatment Done
a. Learners
b. Teachers
c. NTP
Appendix 8
C. No. of Pupils Dewormed
1st Round
2nd Round
D. No. of Pupils Given Iron Supplement
E. No. of Pupils Immunized (Specify vaccine given)
F. No. of consultation attended
1. Learners
2. Teachers
3. NTP
G. Referral (No. Referred to)
1. Physician
2. Dentist
3. Guidance
4. Other facilities
5. RHU/ District/ Provincial Hospital
III. Health Education
No. of Classes given health lectures:
A. No. of orientation training conducted to:
1. Learners
2. Teachers
3. Parents
4. Others (Specify)
B. No. of conferences/meeting with:
1. Teachers/ Adminstrators
2. Health officials
3. Learners
4. Parents
5. LGU/Barangay
6. NGO's/Stakeholders
C. Involvement as Resource Person/ Consultant/ Adviser/ Judge
1. Health Activities/ programs/ contests
2. Class Discussion
3. Health Clubs/ Organization
IV. School Community Activities for Health and Nutrition
A. PTA/ Homeroom Organization Meetings
B. Parent Education Seminar/ Workshop/Training
C. Home Visits Conducted
D. Hospital Visits made
Appendix 8
V. Common Signs & Symptoms
A. Skin and Scalp
1. Presence of Lice (Pediculosis)
2. Redness of Skin
3. White Spots
4. Flaky Skin
5. Minor Injuries
6. Impetigo/Boil
7. Skin Lessions
8. Acne/Pimples
9. Itchiness
B. Eye and Ears
1. Matted eye lashes
2. Eye redness
3. Ocular misalignment (Squint)
4. Eye dischrge
5. Pale conjunctiva
6. Hordeolum
7. Ear discharge
8. Mucos discharge
9. Nose bleeding (epistaxis)
C. Mouth/ Neck / Throat
1. Presence of Lessions
2. Inflammed Pharynx
3. Enlarged tonsils
4. Enlarged lymphnodes
D. Heart and Lungs
1. Rates
2. Murmur
3. Irregular heart rate
4. Wheezes
E. Deformities
1. Acquired (Specify)
2. a. Acquired
Appendix 8
F. Nutritional Status
a. Normal
b. Wasted
c. Severly Wasted
d. Obeese
e. Overweight
f. Stunted
g. Tall
G. Abdomen
1. Abdominal pain
2. Distended
3. Tenderness
4. Dysmenorrhea
H. Dental Service
1. Gingivitis
2. Periodontal Disease
3. Malocclussion
4. Supernumecoary Teeth
5. Retained decidous Teeth
6. Decubital Ulcer
7. Calculus
8. Cleff Lip/ Palate
9. Flourosis
10. Others / Specify
11. Total # of DMFT
12. Total # of dmft
I. Other Signs & Symptoms Noted:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Appendix 8
VI. Remarks:
Prepared by: Noted by:
Name / Designation School Head
Date
