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Republic of the Philippines Document Code: SDO-PM-QF-SGOD-

Department of Education SHN-001


Region III
SCHOOLS DIVISION OF ZAMBALES Revision: 00
Zone 6, Iba, Zambales
Tel./Fax No. (047) 602 1391 Effectivity date: 06-01-2018
E-mail Address: zambales@deped.gov.ph
website: www.depedzambales.ph
Name of Office:
SCHOOL HEALTH EXAMINATION
SGOD – School Health
CARD
and Nutrition Section
Elementary Pupils

NAME _________________________________________________ SCHOOL


_______________________________________________
Date of Birth ___________________________________________ Region
_________________________________________________
Birth Place_____________________________________________ Division
________________________________________________
Parent/Guardian_______________________________________ Contact
Number________________________________________
Address ___________________________________________________________________________________________________________

Kinder Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6


Date of Examination
Temperature/BP
Heart Rate/Pulse
Rate/Respiratory Rate
Height
Weight
Nutritional Status (NS)
Visual Acuity (Snellen’s)
a. N Rt b. N Lft c. AbN Rt, d. AbN
Lft
Skin/Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen/Genitalia
Spine/extremities
Others, specify
Examined by

NS Skin/Scalp Eye/Ear/Nose Mouth/Throat/ Lungs/Heart Abdomen/ Spine/ Remarks/


Neck Genitalia Extremities Intervention
a. a. Normal a. Normal a. Normal Mouth a. Normal a. Normal a. Normal a. Needs
Normal eye lungs spine
Abdomen Supervision
b. b. b. Normal b. Normal Tthroat b. Normal b. Normal b. N upper b. Needs
Below Pediculosis ears heart close
Genitalia Extremities
Normal supervision
c. c. Tinea c. Normal c. Enlarge Tonsils c. rales c. Mass c. N lower c. Needs
Above Flavia Nose with/ w/o follow-up
exudates Extremities
Normal
d. Ringworm d. Squinting d. Lip lesion d. wheeze d. d. Scoliosis d. Corrected
Hemorrhoi
ds
e. Eczema e. Pale e. Enlarge tonsils e. Murmur e. e. Lordosis e. Treated
Conjuctiva with/ w/o Tenderness
exudates
f. Impetigo/ f. Ear f. Inflamed pharynx f. Deformed f. Genital f. Kyphosis f. Advice/
boil Discharge with/w/o exudates chest discharge Counseled
g. Hematoma g. Impacted g. Enlarge thyroid g. Distant g. Hernia g. bowlegs g. Referred
cerumen gland heart knock
sounds knees
h. Bruises h. Septal h. Speech defect h. Irregular h. Others, h. Flat foot h. Parents
deviation heart rate specify Notified
i. Cuts/ i. Nasal i. Dental Problem i. Others, i. Club Foot i. Others,
QM - Page 1 of 3
Republic of the Philippines Document Code: SDO-PM-QF-SGOD-
Department of Education SHN-001
Region III
SCHOOLS DIVISION OF ZAMBALES Revision: 00
Zone 6, Iba, Zambales
Tel./Fax No. (047) 602 1391 Effectivity date: 06-01-2018
E-mail Address: zambales@deped.gov.ph
website: www.depedzambales.ph
Name of Office:
SCHOOL HEALTH EXAMINATION
SGOD – School Health
CARD
and Nutrition Section
Elementary Pupils

lacerations discharge specify specify


j. Allergy j. Others, j. Others, j. Others,
specify specify specify
k. Others,
specify

MEDICAL HISTORY

YES NO Guided Question


Allergy
Asthma Do you have a toothbrush? _______ Y ________ N
Anemia
Bleeding How many times do you brush your teeth? _______ once ________ 2x ________ 3x
Problems
Heart Ailment How many times do you change your toothbrush in a year? _________
Diabetes
Epilepsy Do you use toothbrush in brushing? _______ Y ________ N
Kidney
disease
How many times do you visit the dentist in a year? _______ once ________ 2x
Convulsion
Fainting

QM - Page 2 of 3
Republic of the Philippines Document Code: SDO-PM-QF-SGOD-
Department of Education SHN-001
Region III
SCHOOLS DIVISION OF ZAMBALES Revision: 00
Zone 6, Iba, Zambales
Tel./Fax No. (047) 602 1391 Effectivity date: 06-01-2018
E-mail Address: zambales@deped.gov.ph
website: www.depedzambales.ph
Name of Office:
SCHOOL HEALTH EXAMINATION
SGOD – School Health
CARD
and Nutrition Section
Elementary Pupils

QM - Page 3 of 3

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