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 Republic of the Philippines
DEPARTMENT OF EDUCATION

Pasig City

SCHOOL HEALTH EXAMINATION CARD

Name: School ID: 132883
Last First Middle
LRN:

Date of Birth Region: CARAGA

Month Day Year

Birth Place: Division: SURIGAO DEL SUR

Parent/Guardian Telephone No.:
Address:

Grade Grade Grade Grade Grade Grade

Kinder/ Grade 1/ Grade 2 3 / 4 / Grade 5 6/ 7/ Grade 9/ Grade 10/ 11 / Grade
SPED SPED / SPEd SPED SPED / SPED SPED SPED 8/ SPED SPED SPED SPED 12 / SPED

Findings

Findings

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Findings
Date of Examination
Temperature / BP
Heart Rate / Pulse Rate / Respiratory Rate
Height
Weight
Nutritional Status (NS) (BMI / Wt-for-Age)
Nutrition 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 Supplement (P or X )
Deworming (P or X )
Immunization (Specify what kind)
SBFP Beneficiary (P or X )
4Ps Beneficiary (P or X )
Menarche (P or start)
Others, specify
Examined by:
LEGEND
Vision / Auditory
NS Skin / Scalp Eye/ Ear / Nose Mouth / Neck Throat Lungs / Heart Abdomen Deformation
Screening
a. Normal Weight a. Passed a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired

b. Wasted Underweight b. Failed b. Presence of Lice b. Stye b. Enlarged Tonsils b. Rales b. Distended b. Congenite
c. Severly Wasted /
c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain Specify
Underweight
d. Overweight d. White Spots d. Ocular Misalignment d. Inflamed Pharynx d. Murmur d. Tenderness

e. Obese e. Flaky Skin e. Pale Conjunctive e. Enlarged lymphnosis h. Irregular Heart Rate e. Dysmenorrhea

f. Normal Height f. Impetigo / Boil f. Ear Discharge f. others, specify i. Other, Specify f. Other Specify

g. Stunted g. Hematoma g. Impacted Cerumen

h. Severely Stunted h. Bruises / Injuries h. Mucus discharge

i. Tall i. Itchiness i. Nose Bleeding (Epistaxis)

j. Skin Lessions j. Eye discharge

k. Acne / Pimple k. Matted Eyelashes

Note: Use Letter to record ailments and Place X if not examined

 INTERVENTION / TREATMENT RECORD

ATTENDED BY
DATE CHIEF COMPLAINT INTERVENTION / TREATMENT DONE REMARKS
(Name/ Position)

SCHOOL ORAL HEALTH EXAMINATION CARD

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

PERMANENT TEETH
PERMANENT 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

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

PERMANENT 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
 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

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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

PERMANENT TEETH
PERMANENT 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

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. ____________________ GRADE 7 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

PERMANENT 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

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 8 S.Y. ____________________ GRADE 9 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

PERMANENT 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

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 10 S.Y. ____________________ GRADE 11 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

PERMANENT 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
 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 12 S.Y. ____________________ ORAL HEALTH

1⁄7 2⁄8 3⁄9 4⁄10 5⁄11 6⁄12

Kinder
Gingivitis
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Periodontal Disease
TEMPORARY TEETH Malocclussion
Supernumeracy Teeth
PERMANENT TEETH Retained decidious teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Dedubital Ulcer
Calculus
Cleft Lip/Palate
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Root fragment
Flourosis
Other, Specify
TEMPORARY TEETH

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

TEMPORARY TEEH PERMANENT TEETH

1⁄7 2⁄8 3⁄9 4⁄10 5⁄11 6⁄12
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 (P) - Sound/erupted Permanent Tooth FB - Fixed Bridge
D - Carious tooth indicated for filling RFS - Pit and Fissure Sealant CD - Complete Denture
RF - Root fragment JC - Jacket Crown GI - Glass lonomer
M - Missing tooth PFS - Pontic CO - Composite
F2 - Permanently filled tooth with RPD - Removable partial Denture AM - Amalgan
recurrence for decay

INTERVENTION / TREATMENT RECORD

Intervention / Treatment
Date Chief Complaint Remarks Attended by (Name/Position)
Done
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Name: _____________________________________________Division: ______________________ Department: _________________________
Date of Birth ________________________________________ Type of Work: __________________ Sex: ___________ Civil Status: __________

1 Date Date Date

Height Height Height
Weight Weight Weight
2 Temperature
3 Respiratory System:
Fuorography
Sputum Analysis:
4 Circulatory System:
Blood Pressure
Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test
5 Digestive System
Genito-Urinary
6 Urinalysis, etc.
7 Skin:
8 Locomotor System
9 Nervous System
Eyes:
10 Color Perception:
Vision:
With glasses: Far: Near: With glasses: Far: Near: With glasses: Far: Near:
11 Without glasses: Far: Near: Without glasses: Far: Near: Without glasses: Far: Near:
12 Nose:
13 Ear:
Hearing:
14 Right: Left Right: Left: Right: Left:
15 Throat
16 Teeth and Gums
17 Immunization:
18 Remarks
19 Recommendation
Employee's Signature
20 Employee's Name (Print)
21 Physician's Signature:
Physician's Name (Print)