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 day: Packs 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:
