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: XI
Month Day Year
Birthplace: Division: DAVAO CITY
Parent/Guardian: Telephone No.:
Address:

Kinder/ Grade 1/ Grade 2/ Grade 3/ Grade 4/ Grade 5/ Grade 6/ Grade 7/ Grade 8/ Grade 9/
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED

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
Screening
a. Normal a. Passed a. Normal a. Normal a. Normal a. Normal a. Normal
Weight
b. Wasted/ b. Failed b. Presence of Lice b. Stye b. Enlarged tonsils b. Rales b. Distended
Underweight
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 d. Inflamed pharynx e. Murmur d. Tenderness
Misalignment
2018 SHD Form 2
e. Obese e. Flaky Skin E. Pale Conjunctiva e. Enlarged lymphnodes h. Irregular heart rate e. Dysmenorrhea

f. Normal Height f. Impetigo/ boil f. Ear discharge f. Others , specify i. Others, specify f. Others, 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 discharge

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
IC OF THE PHILIPPINES
MENT OF EDUCATION
ORT SERVICES - SCHOOL HEALTH DIVISION
Pasig City

TH EXAMINATION CARD

XI

Grade 10/ Grade 11/ Grade 12/

SPED SPED SPED

Findings

Findings

Findings

Abdomen Deformities
a. Normal a. Acquired

b. Distended b. Congenital
(Specify)
c. Abdominal Pain

d. Tenderness
2018 SHD Form 2
e. Dysmenorrhea

f. Others, Specify
2018 SHD Form 2
INTERVENTION/TREATMENT RECORD

A
Date Chief Complaint Intervention/Treatment Done Remarks (N

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

TEMPORARY TEETH TEMPORARY TEETH
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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
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

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

 2018 SHD Form 2
/TREATMENT RECORD

Attended by
(Name/Position)

LTH EXAMINATION CARD

64 65 LEFT
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24 25 26 27 28

34 35 36 37 38

74 75 LEFT
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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

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
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

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

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

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
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

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72

GRADE 6/12 S.Y. ORAL HEALTH CONDITION

Kinder
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Gingivitis
2018 SHD Form 2
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
2018 SHD Form 2

64 65 LEFT

24 25 26 27 28

34 35 36 37 38

74 75 LEFT

63 64 65 LEFT

23 24 25 26 27 28

33 34 35 36 37 38

73 74 75 LEFT

ORAL HEALTH CONDITION

1 2 3 4 5 6
7 8 9 10 11 12
2018 SHD Form 2
2018 SHD Form 2

TEMPORARY TEETH dft index PERMANENT TEETH

Index d.f.t. Kinder 1 2 3 4 5 6 Index D.M.F.T. Kinder
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 Br
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant CD - Comple
RF - Root fragment JC - Jacket Crown GI - Glass Io
O - Missing tooth P - Pontic SyF - Compos
F2 - Permanently filled tooth with RPD - Removable Partial Denture AgF - Amalga
recurrence of decay

INTERVENTION/TREATMENT RECORD

Date Chief Complaint Intervention/Treatment Done Remarks Attende

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 2018 SHD Form 2

1 2 3 4 5 6
7 8 9 10 11 12

Fixed Bridge
Complete Denture
Glass Ionomer
Composite
Amalgan

/TREATMENT RECORD

Attended by (Name/Position)
2018 SHD Form 2