2018 SHD Form 2

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION
REGI0N 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 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
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Height (in cm)
Weight (in kg)
Nutritional Status (NS) (BMI/Wt-for-Age)
Nutritional 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 Supplementation (√ or X)
Deworming (√ or X)
Immunization (Specify what kind)
SBFP Beneficiary (√ or X)
4Ps Beneficiary (√ or X)
Menarche (√ the Start)
Others, specify
Examined by:
LEGEND:
Vision/ Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Lungs/Heart Abdomen Deformities
Screening
a. Normal a. Passed a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
Weight
b. Wasted/ b. Failed b. Presence of Lice b. Stye b. Enlarged tonsils c. Rales b. Distended b. Congenital
Underweight (Specify)
c. Severely c. Redness of Skin c. Eye Redness c. Presence of lesions d. Wheeze c. Abdomnial Pain
Wasted/Underwt

d. Overweight d. White Spots d. Ocular Misalignment d. Inflamed pharynx e. Murmur d. Tenderness

e. Obese e. Flaky Skin E. Pale Conjunctiva e. Enlarged lymphnodes h. Irregular heart rate e. Dysmenorrhea

f. Normal Height f. Impetigo/ f. Ear discharge f. Others , specify i. Others, f. Others, Specify
boil specify
g. Stunted g. Hematoma g. Impacted cerumen

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

Stunted
i. Tall i. Itchiness i. Nose Bleeding
(Epistaxis)
j. Skin Lessions j. Eye dischrge
2018 SHD Form 2
k. Acne/Pimple k. Matted Eyelashes
Note: Use Letter to record ailments and Place X if not examined
2018 SHD Form 2

INTERVENTION/TREATMENT RECORD

Date Chief Complaint Intervention/Treatment Done Remarks Attended by (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

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
2018 SHD Form 2

2
 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION
REGI0N VII -DIVISION OF CEBU PROVINCE

School Name/ID

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:

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

Name of Learner: 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 gr
__ Others:

3.       Have you ever had surgery/ hospitalization? Yes No

If Yes, please specify details.

4.       Does anyone in your family have the following conditions: Yes No
__ Tuberculosis
__ Cancer If yes, what kind?
__ Stroke
__ Diabetes Mellitus
__ Hypertension
__ Depression
__ Others:

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 is correct.

Name & Signature of Parent/Guardian Date

Annex 7: Rapid Psychosocial Form
Name:
Grade/Section:
School:
Contact Number:

Control Number :  DATE:                       

□ Health
Ang checklist ay □School □ Lying-in □ Hospital □ Others:
Center
sinagutan sa: 

Sagutin ng tapat ang mga sumusunod na katananungan. Ang sagot ay CONFIDENTIAL.

□ 
1.      Ikaw ba ay nakakaranas ng pananakit o pananakot sa inyong  □ Hindi    Oo         
tahanan/ bahay?    

□ 
2.      May mga pagkakataon ba na pinag –isipan mong maglayas o □ Hindi   
Oo         
umalis na ng inyong bahay? 
□ 
□
3.      Nakaranas ka ba ng bullying na pisikal o cyber bullying sa paaralan o Hindi        Oo          
sa trabaho ?        

□ □ 
4.      May pagkakataon ba na seryoso mong naisip na wakasan ang iyong Hindi       Oo        
buhay?     
□
Hindi         □  Oo
5.      Naninigarilyo ka ba?    
□
Hindi         □  Oo
6.      Umiinom ka ba ng alak?           

7.      Nakakita ka na ba ng mga ipinagbabawal na "gamut" o drugs?

□
8.      Ikaw ba ay nakaranas ng magkarelasyon (boyfriend / girlfriend)?      Hindi         □  Oo  
  
□
Hindi         □  Oo  
9.      Ikaw ba ay nakaranas ng makipag sex o makipagtalik?     

□ Hindi □ Oo     
10.   Nakaranas ka ba na ikaw ay pinilit  makipag sex ?      

□ Hindi □ Oo     
11.   Ikaw ba ay nakaranas  nang mabuntis, o makabuntis ?     

□ Hindi □ Oo     
12.   Gusto mo bang mag pa counsel o komunsulta para matulungan ka?

Para sa mga impormasyon tungkol sa iyong kalusugan o anumang pangangailangang

pagkonsulta,  maari kang  tumawag sa ___09333257007 o 09606764835.

mag e-mail sa _______________________________________________________

bumisita sa FB page _________________________________________________

 REPUBLIKA ng PILIPINAS
Rehiyon VII

SULAT PAHIBALO
DIVISION: CEBU PROVINCE
SCHOOL:
ADDRESS:
DATE:
STUDENT's NAME:
STUDENT's ADDRESS:
NAME of PARENT / GUARDIAN:

Tinahod namong mga Ginikanan / Guardian ,

Ang Departamento sa Edukasyon inubanan sa Departamento sa Panglawas ug sa Local nga

Pangagamhanan ug mga Magtutudlo magpasiugda ug dakung kalihokan sa pagpamurga sa mga tinun-an
nga walay bayad aron mapanalipdan and mga tinun-an sa bitok.
Kini nga tulungha-an uban sa lokal nga buhatan sa maayong panglawas mohatag ug serbisyo alang sa
pagpamurga matag-tuig sa tanang tinun-an.
Ipahigayon kini sa tibuok bulan sa Octobre ug Mayo niining tuig 2023 - 2024 Kining sulata gipadala
aron sa pagpahibalo kaninyo mahitungod sa maong kalihokan. Palihug ug marka sa kahon nga makita sa ubos ani nga
sulat alang sa inyong tubag sa pag-uyon o dili sa pag PURGA..

Alang sa dugang pangutana o impormasyon mahitungod niini, palihog sa pagpakisayod sa Principal/Teacher s

tulunghaan o sa Lokal Pangagamhanan sa maayong panglawas o sa atong School Nurse 09333257007.
Daghang salamat.
Kanimo matinud-anon,

Ngalan ug Pirma sa School Head / Principal

TUBAG / SANONG SA SULAT O PAGTUGOT

Agi ug pagsanong sa Sulat Pahibalo mahitungod sa pagahimoong Pamakuna sa tunghaan diin nagtung-ha
ang ako anak, ako nakabasa ug nakasabot sa gipahibalo nga pagpamakuna.

Ako nagatugot nga ang akong anak nga si__________________________________________ mapurga.

(Pangalan sa Bata)

Ako dili motugot, tungod kay .

Ngalan ug Pirma sa Magtutudlo Ngalan ug Pirma sa Ginikanan / Guardian

 ,

ug sa Local nga
a mga tinun-an

rbisyo alang sa

ng sulata gipadala
akita sa ubos ani nga

sa Principal/Teacher s
09333257007.

l Head / Principal

aan diin nagtung-ha

______ mapurga.

anan / Guardian
2018 SHD Form 2

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. 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

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 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

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 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

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

3
 PERMANENT

PERMANENT
2018 SHD Form 2

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

3
2018 SHD Form 2

GRADE 12 S.Y. ORAL HEALTH CONDITION

1 2 3 4 5 6
Kinder 7 8 9 10 11 12

Gingivitis
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Periodontal Disease
TEMPORARY TEETH Malocclussion
Supernumerary teeth
Retained decidous teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Decubital ulcer
PERMANENT TEETH

Calculus
Cleft lip / palate
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Root fragment
Fluorosis
Others, Specify
TEMPORARY TEETH

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

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 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
M - Missing tooth PFS - Pontic CO - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AM - Amalgan
recurrence of decay

INTERVENTION/TREATMENT RECORD

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