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Health Examination Form

This document is a school health examination card used in the Philippines to record student health information over several grades. It includes sections to record a student's name, birthdate, address and parent/guardian information. There are also tables to document annual health examinations from kindergarten through 12th grade. Examination findings are recorded for temperature, height, weight, nutrition status, vision and hearing screenings, and checks of the skin, eyes, ears, nose, mouth, throat, lungs, heart, abdomen and deformities. Notes sections allow recording of any illnesses, interventions/treatments and the attending medical professional.

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Vangie Marikit
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59 views4 pages

Health Examination Form

This document is a school health examination card used in the Philippines to record student health information over several grades. It includes sections to record a student's name, birthdate, address and parent/guardian information. There are also tables to document annual health examinations from kindergarten through 12th grade. Examination findings are recorded for temperature, height, weight, nutrition status, vision and hearing screenings, and checks of the skin, eyes, ears, nose, mouth, throat, lungs, heart, abdomen and deformities. Notes sections allow recording of any illnesses, interventions/treatments and the attending medical professional.

Uploaded by

Vangie Marikit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Republic of the Philippines

Department of Education
BUREAU OF LEARNER SUPPORT SERVICES- SCHOOL HEALTH DIVISION
REGION VII - DIVISION OF CEBU PROVINCE
SCHOOL HEALTH EXAMINATION CARD

Name: ________________________________________________ School ID: ________________________________


Last First Middle
LRN: ___________________________________
Date of Birth: ___________________________________________ Region: ________________________________
Month Day Year
Birthplace: _____________________________________________ Division: ________________________________
Parent/Guardian: _________________________________________ Telephone No: ________________________________
Address: ______________________________________________

KINDER GRADE I GRADE II GRADE III GRADE IV GRADE V GRADE VI

Findings Findings Findings Findings Findings Findings Findings

Date of Examination

Temperature/BP

Heart Rate/Pulse Rate/Respiratory Rate

Height (cm)

Weight (kg)

Nutritional Status (NS) (Height-for-Age)

Nutritional Status (NS) (BMI/Wt-for-Age)

Vision Screening using appropriate chart

Auditory Screening (Tuning Fork)

Skin/Scalp

Eyes/Ears/Nose

Mouth/Throat/Neck

Lungs/Heart

Abdomen

Deformities

Iron Supplementation (/ or X)

Deworming (/ or X)

Immunization (Specify what kind)

SBFP Beneficiary (/ or X)

4Ps Beneficiary (/ or X)

Menarche (/ or X)

Others, specify

Examined by:

Vision/Auditory Mouth/Neck/
NS Skin/Scalp Eye/Ear/Nose Lungs/Heart Abdomen Deformities
Screening Throat

a. Normal Weight a. Passed a. Normal a. Normal a. Normal a. Abnormal a. Normal a. Acquired

b. Wasted/ b. Failed b. Presence of Lice b. Stye b. Enlarged b. Rales b. Distended b. Congenital

Underweight c. Redness of skin c. Eye redness tonsils c. Wheeze c. Abdominal pain (Specify)

c. Severely wasted/ d. White spots d. Ocular Misalignment c. Presence of d. Murmur d. Tenderness

Underweight e. flaky skin e. Pale conjunctiva lesions e. Irregular heart e. Dysmenorrhea

d. Overweight f. impetigo/boil f. Ear Discharge d. Inflamed phar rate f. Others (specify)

e. Obese g. Hematoma g. Impacted Cerumen e. Enlarged f. Cough

f. Normal Weight h. Bruises/Injuries h. Mucus Discharge lymphnodes g. Colds


g. Stunted i. Itchiness i. Nose Bleeding f. Others (specify h. others, Specify

h. Severely Stunted j. skin lessions (Epistaxis)


i. Tall k. Acne/Pimple j. Eye Discharge

k. Matted Eyelashes

Note: Use letter to record ailments


Attended by
Date Chief Complaint Intervention/Treatment Done Remarks
(Name/Position)
Republic of the Philippines
Department of Education
BUREAU OF LEARNER SUPPORT SERVICES- SCHOOL HEALTH DIVISION
REGION VII - DIVISION OF CEBU PROVINCE
SCHOOL HEALTH EXAMINATION CARD

Name: ________________________________________________ School ID: ________________________________


Last First Middle
LRN: ___________________________________
Date of Birth: ___________________________________________ Region: ________________________________
Month Day Year
Birthplace: _____________________________________________ Division: ________________________________
Parent/Guardian: _________________________________________ Telephone No: ________________________________
Address: ______________________________________________

VII VIII IX X XI XII

Findings Findings Findings Findings Findings Findings

Date of Examination

Temperature/BP

Heart Rate/Pulse Rate/Respiratory Rate

Height (cm)

Weight (kg)

Nutritional Status (NS) (Height-for-Age)

Nutritional Status (NS) (BMI/Wt-for-Age)

Vision Screening using appropriate chart

Auditory Screening (Tuning Fork)

Skin/Scalp

Eyes/Ears/Nose

Mouth/Throat/Neck

Lungs/Heart

Abdomen

Deformities

Iron Supplementation (/ or X)

Deworming (/ or X)

Immunization (Specify what kind)

SBFP Beneficiary (/ or X)

4Ps Beneficiary (/ or X)

Menarche (/ or X)

Others, specify

Examined by:

Vision/Auditory Mouth/Neck/
NS Skin/Scalp Eye/Ear/Nose Lungs/Heart Abdomen Deformities
Screening Throat

a. Normal Weight a. Passed a. Normal a. Normal a. Normal a. Abnormal a. Normal a. Acquired

b. Wasted/ b. Failed b. Presence of Lice b. Stye b. Enlarged b. Rales b. Distended b. Congenital

Underweight c. Redness of skin c. Eye redness tonsils c. Wheeze c. Abdominal pain (Specify)

c. Severely wasted/ d. White spots d. Ocular Misalignment c. Presence of d. Murmur d. Tenderness

Underweight e. flaky skin e. Pale conjunctiva lesions e. Irregular heart e. Dysmenorrhea

d. Overweight f. impetigo/boil f. Ear Discharge d. Inflamed pharynx rate f. Others (specify)

e. Obese g. Hematoma g. Impacted Cerumen e. Enlarged f. Cough

f. Normal Weight h. Bruises/Injuries h. Mucus Discharge lymphnodes g. Colds


g. Stunted i. Itchiness i. Nose Bleeding f. Others (specify) h. others, Specify
h. Severely Stunted j. skin lessions (Epistaxis)
i. Tall k. Acne/Pimple j. Eye Discharge

k. Matted Eyelashes

Note: Use letter to record ailments


Attended by
Date Chief Complaint Intervention/Treatment Done Remarks
(Name/Position)

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