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 accord-
ance 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 require-
ments 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
Medical History (For Learners)
1. Do you have any allergies? ___ Yes ___ No
If Yes, please identify below:
__ Medicine __ Stinging Insects
__ Pollens __ Others: __________________
__ Food
2. Do you have any ongoing medical condition? ___ Yes ___ No
If Yes, please identify below:
__ Error of refraction __ Anemia
__ Asthma __ Bleeding disorder
__ Seizure __ Hernia (painful bulge in the groin area)
__ Heart problem __ 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 __ Hypertension
__ Cancer __ Depression
__ Stroke __ Others
__ Diabetes Mellitus If yes, what kind? : __________________
5. Exposure to cigarette/vape smoke at home? ___ Yes ___ No
6. Which hand is used for writing?
___ Right ___ Left ___ Both
I certify that the above information are correct.
__________________________________ _____
Name & Signature of Parent/Guardian Date
SHD Form 1-A
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 Grade Grade
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED 10/ SPED 11/ SPED 12/ 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/ Audito-
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities
ry Screening
a. Normal a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
Vision
Weight (Specify)
: a. L R b. Presence of b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended
Passed Lice
c. Severely b. L R c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain b. Congenital
Wasted/ Failed (Specify)
d. Overweight d. White Spots d. Ocular Misalign- d. Inflamed pharynx d. Murmur d. Tenderness
Auditory
ment
e. Obese a. L R e. Flaky Skin e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart rate e. Dysmenorrhea
Passed
f. Normal Height b. L R f. Impetigo/boil f. Others , specify f. Others, Specify
f. Matted Eyelashes f. colds
Failed
g. Stunted g. Hematoma g. Eye Discharge g. Cough
h. Severely h. Bruises/ Inju- h. Ear dischrage h. Others, specify
Stunted ries
i. Tall i. Itchiness i. Impacted ceru-
men
j. Skin Lessions j. Mucus discharge
k. Acne/Pimple k. Nose Bleeding
(Epistaxis)
l. Capillary refill l. Others, specify
greater than 3
m. others, specify
Note: Use Letter to record ailments and Place X if not examined
