SHD Form 1
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region ______________
Division of _____________________
______________________________________________
School Name/ID
SCHOOL HEALTH EXAMINATION CARD
Name:
Last First Middle
Date of Birth: Birthplace:
Month / Day / Year
School ID: Region:
Learner Reference Number (LRN): Division:
Parent/Guardian: Telephone 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.
Name and Signature of Child Name and Signature of Parent
SHD Form 1-A
Name : ________________________________________ LRN : ______________________
Medical History (For Learners)
1. Do you have any allergies? Yes No
If Yes, please identify below:
__ Medicine
__ Pollens
__ Food
__ Stinging Insects
__ Others:
2. Do you have any ongoing medical condition? Yes No
If Yes, please identify below:
__ Error of refraction
__ Asthma
__ Seizure
__ Heart problem
__ Anemia
__ Bleeding disorder
__ Hernia (painful bulge in the groin area)
__ Others:
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
__ Cancer If yes, what kind?
__ Stroke
__ Diabetes Mellitus
__ Hypertension
__ Depression
__ Others______________________________________
5. Exposure to cigarette/vape smoke at home? Yes No
I certify that the above information are correct.
Name & Signature of Parent/Guardian Date
SHD Form 1-B
Name : ________________________________________ LRN : _______________________________________
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
Vision Screening using appropriate chart
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 Screening Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities
a. Normal Weight a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
Vision (Specify)
: a. Passed L R b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended
c. Severely b. Failed L R c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain b. Congenital
Wasted/Underwt (Specify)
d. Overweight d. White Spots d. Ocular Misalignment d. Inflamed pharynx d. Murmur d. Tenderness
Auditory
e. Obese a. Passed L R e. Flaky Skin e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart rate e. Dysmenorrhea
f. Normal Height b. Failed L R 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 Stunted h. Bruises/ Injuries h. Ear dischrage h. Others, specify
i. Tall i. Itchiness i. Impacted cerumen
j. Skin Lessions j. Mucus discharge
k. Acne/Pimple k. Nose Bleeding
(Epistaxis)
l. Capillary refill l. Others, specify
greater than 3
seconds
m. others, specify
Note: Use Letter to record ailments and Place X if not examined
SHD Form 1-C
Name : ____________________________________________ LRN : __________________________________
Medical Treatment Record
Attended by
Date Chief Complaint Intervention/Treatment Done Remarks (Name/Position)
2
SHD Form 1-D
Name : ____________________________________________ LRN : __________________________________
Dental Findings
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 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
2
SHD Form 1-Da
Name : ____________________________________________ LRN : __________________________________
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 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 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
SHD Form 1-Db
Name : ____________________________________________ LRN : __________________________________
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)
