1 2 3 5 6 7

DATE OF BIRTH

NAME LRN PICTURE

MONTH DAY YEAR

ROBIN C. BAJA 12345678910 AUGUST 21 1978

JERICHO A. ROSALES 54321098765

8 9 10

BIRTHPLACE PARENT/GUARDIAN CONTACT NO.

DAVAO CITY REYNALDO T. BAJA 09106772715

11 12 13 14 15

Grade 7 Grade 7 Grade 7 Gr

ADDRESS
Temperature/ Heart Rate/Pulse Height (in
Date of Rate/Respiratory
Examination BP cm)
Rate

CALINAN, DAVAO CITY 6/1/2019 120/80 70 158

 16 17 18 19 20 21 22 23 24

Grade 7 Grade 7 Grade 7 Grade 7 Grade 7 Grade 7

Vision
Nutritional Nutritional Screening Auditory Eyes/E Mouth/Th Lungs/Hea
Weight Status (NS) Status (NS) Screening Skin/
using ars/N roat/Neck
(in kg) (BMI/Wt-for- (Height-for- appropriat (Tuning Scalp rt
ose
Age) Age) Fork)
e chart

64 A A A A A A A A
 25 26 27 28 29 30 31 32

ade 7 Grade 7 Grade 7 Grade 7 Grade 7

Iron Immuniza SBFP 4Ps Menarche
Suppleme Deworming tion
Abdomen Deformities ntation (√ (√ or X) Beneficiar Beneficiar (√ the
(Specify y (√ or X) y (√ or X) Start)
or X) what kind)

A A / / K / X L
 33 34 35 36 37 38 39 40

e7 Grade 8 Grade 8 Grade 8 Grade 8 Gr

Nutritiona Nutritiona
Heart
Temperatur Rate/Pulse Height (in Weight (in l Status l Status
Date of
Others, specify Examination (NS) (NS)
e/BP Rate/Respirato cm) kg) (BMI/Wt- (Height-
ry Rate for-Age) for-Age)

M A B C D E F G
 41 42 43 44 45 46 47 48 49

Grade 8 Grade 8 Grade 8 Grade 8 Grade 8 Grad

Vision Auditory Iron
Screening Screening Skin/ Eyes/Ears/ Mouth/Th Lungs/Hea Abdomen Deformities Suppleme
using
appropriat (Tuning Scalp Nose roat/Neck rt ntation (√
Fork) or X)
e chart

H I J K L M N O P
 50 51 52 53 54 55 56 57

ade 8 Grade 8 Grade 8 Grade 9 Grade 9

Immuniza SBFP 4Ps Menarche
Dewormin tion Others, Date of Temperature
Beneficiar Beneficiar (√ the
g (√ or X) (Specify y (√ or X) y (√ or X) Start) specify Examination /BP
what kind)

Q R S T U V A B
 58 59 60 61 62 63 64 65 66

ade 9 Grade 9 Grade 9 Grade 9 Grade 9 Grade 9

Nutritiona Nutritiona Vision
Heart Auditory
Rate/Pulse Height (in Weight (in l Status l Status Screening Screening Skin/ Eyes/Ears/
(NS) (NS) using
Rate/Respir cm) kg) (Tuning Scalp Nose
(BMI/Wt- (Height- appropriat
atory Rate Fork)
for-Age) for-Age) e chart

C D E F G H I J K
 67 68 69 70 71 72 73 74 75

9 Grade 9 Grade 9 Grade 9 Grade 9 Grade 9

Iron
Mouth/Th Lungs/Hea Abdomen Deformitie Suppleme Deworming Immunizatio SBFP 4Ps
n (Specify Beneficiary Beneficiary
roat/Neck rt s ntation (√ (√ or X) what kind) (√ or X) (√ or X)
or X)

L M N O P Q R S T
 76 77 78 79 80 81 82 83 84

Grade 9 Grade 10 Grade 10 Grade 10 Grad

Heart Nutritiona Nutritiona
Date of Temperatu Rate/Pulse Height (in Weight (in l Status l Status
Menarche Others, Examinatio re/BP Rate/Respi (NS) (NS)
(√ the Start) specify cm) kg)
n ratory (BMI/Wt- (Height-
Rate for-Age) for-Age)

U V A B C D E F G
 85 86 87 88 89 90 91 92 93

de 10 Grade 10 Grade 10 Grade 10 Grade 10 Grad

Vision Auditory Iron
Screening Screening Skin/ Eyes/Ears/ Mouth/Th Lungs/Hea Abdomen Deformitie Suppleme
using
appropriat (Tuning Scalp Nose roat/Neck rt s ntation (√
Fork) or X)
e chart

H I J K L M N O P
 94 95 96 97 98 99 100 101

rade 10 Grade 10 Grade 10 Grade 11 Grade

Deworming Immunizatio SBFP 4Ps Date of
Menarche Others,
n (Specify Beneficiary Beneficiary Examinati Temperatur
(√ or X) what kind) (√ the Start) specify e/BP
(√ or X) (√ or X) on

Q R S T U V A B
 102 103 104 105 106 107 108 109 110

de 11 Grade 11 Grade 11 Grade 11 Grade 11 Grad

Nutritiona Nutritiona Vision
Heart Auditory
Rate/Pulse Height (in Weight (in l Status l Status Screening Screening Skin/ Eyes/Ears/
(NS) (NS) using
Rate/Respir cm) kg) (Tuning Scalp Nose
(BMI/Wt- (Height- appropriat
atory Rate Fork)
for-Age) for-Age) e chart

C D E F G H I J K
 111 112 113 114 115 116 117 118 119

ade 11 Grade 11 Grade 11 Grade 11 Grade 11

Iron Immuniza SBFP 4Ps
Mouth/Th Lungs/Hea Abdomen Deformities Suppleme Dewormin tion Beneficiar Beneficiar
roat/Neck rt ntation (√ g (√ or X) (Specify y (√ or X) y (√ or X)
or X) what kind)

L M N O P Q R S T
 120 121 122 123 124 125 126 127 128

Grade 11 Grade 12 Grade 12 Grade 12 Grade 1

Heart Nutritiona Nutritiona
Menarche Date of Temperatu Rate/Pulse Height (in Weight (in l Status l Status
Others,
(√ the Examinati re/BP Rate/Respi (NS) (NS)
specify cm) kg)
Start) on ratory (BMI/Wt- (Height-
Rate for-Age) for-Age)

U V A B C D E F G
 129 130 131 132 133 134 135 136 137

e 12 Grade 12 Grade 12 Grade 12 Grade 12 Grade

Vision Auditory Iron
Screening Screening Skin/ Eyes/Ears/ Mouth/Th Lungs/Hea Abdomen Deformities Suppleme
using
appropriat (Tuning Scalp Nose roat/Neck rt ntation (√
Fork) or X)
e chart

H I J K L M N O P
 138 139 140 141 142 143

ade 12 Grade 12 Grade 12

Immuniza SBFP 4Ps Menarche
Dewormin tion Others,
Beneficiar Beneficiar (√ the
g (√ or X) (Specify y (√ or X) y (√ or X) Start) specify
what kind)

Q R S T U V
 1
Name Date Chief Complaint
ROBIN C. BAJA 5/21/2019 Sample
JERICHO A. ROSALES 5/22/2019
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 1
Intervention/Treatment Done Remarks
Sample Sample
 Attended by (Name/Position) Date Chief Complaint
Sample
 2
Intervention/Treatment Done Remarks
Attended by (Name/Position) Date Chief Complaint
 3
Intervention/Treatment Done Remarks
Attended by (Name/Position) Date Chief Complaint
 4
Intervention/Treatment Done Remarks
Attended by (Name/Position) Date Chief Complaint
 5
Intervention/Treatment Done Remarks
Attended by (Name/Position) Date Chief Complaint
 6
Intervention/Treatment Done Remarks
Attended by (Name/Position)
2018 SHD Form 2

DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION
Pasig City

SCHOOL HEALTH EXAMINATION CARD

Name: ROBIN C. BAJA School ID: 304346
LRN: 12345678910
Date of Birth: AUGUST 21 1978 Region: XI
Month Day Year
Birthplace: DAVAO CITY Division: DAVAO CITY
Parent/Guardian: REYNALDO T. BAJA Telephone No.:09106772715
Address: CALINAN, DAVAO CITY
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 6/1/19 A A
Temperature/BP 120/80 B B
Heart Rate/Pulse Rate/Respiratory Rate 70 C C
Height (in cm) 158 D D
Weight (in kg) 64 E E
Nutritional Status (NS) (BMI/Wt-for-Age) A F F
Nutritional Status (NS) (Height-for-Age) A G G
Vision Screening using appropriate chart A H H
Auditory Screening (Tuning Fork) A I I
Skin/ Scalp A J J
Eyes/Ears/Nose A K K
Mouth/Throat/Neck A L L
Lungs/Heart A M M
Abdomen A N N
Deformities A O O
Iron Supplementation (√ or X) / P P
Deworming (√ or X) / Q Q
Immunization (Specify what kind) K R R
SBFP Beneficiary (√ or X) / S S
4Ps Beneficiary (√ or X) X T T
Menarche (√ the Start) L U U
Others, specify M V V
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 h. Irregular heart rate e. Dysmenorrhea
lymphnodes
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

RTMENT OF EDUCATION
PORT SERVICES - SCHOOL HEALTH DIVISION
Pasig City

LTH EXAMINATION CARD

304346

XI

09106772715

Grade 10/ Grade 11/ Grade 12/

SPED SPED SPED

Findings

Findings

Findings
A A A
B B B
C C C
D D D
E E E
F F F
G G G
H H H
I I I
J J J
K K K
L L L
M M M
N N N
O O O
P P P
Q Q Q
R R R
S S S
T T T
U U U
V V V

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
Name: ROBIN C. BAJA
A
Date Chief Complaint Intervention/Treatment Done Remarks (N
5/21/2019 Sample Sample Sample

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
2018 SHD Form 2

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)
Sample

LTH EXAMINATION CARD

64 65 LEFT
2018 SHD Form 2

24 25 26 27 28

34 35 36 37 38

74 75 LEFT
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

2018 SHD Form 2
 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
 Appendix 8
HNC NS Form 3
Republic of the Philippines
Department of Education
Region XI
Division of Davao City

ANNUAL HEALTH SERVICES ACCOMPLISHMENT REPORT (DISTRICT / CLUSTER)

SY: ________________________

Name of District/Cluster:

Total No. of Elem. / Sec. Schools:

Total No. of Elem. / Sec. Schools Visited:

I. General Information
A. Distrct / Cluster Enrolment
1. Male
2. Female
B. No. of District / Cluster 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. Congenital (Specify)
 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 District Supervisor / Cluster Head

Date
 Appendix 8
HNC NS Form 3
Republic of the Philippines
Department of Education
Region XI
Division of Davao City

ANNUAL HEALTH SERVICES ACCOMPLISHMENT REPORT (SCHOOL)

SY: ________________________

Name of School: School ID No.:

Total No. times Elem. / Sec. School 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. Congenital (Specify)
 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