SHD Form 1: Medical Records

SHD Form 1

Republic of the Philippines DEPARTMENT OF EDUCATION Region ______________ Division of _____________________ ______________________________________________ School Name/ID

SCHOOL HEALTH EXAMINATION CARD Name: Last

First

Date of Birth:

Middle 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 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

SHD Form 1-A

Name : ________________________________________ LRN : ______________________ Medical History (For Learners) 1.       Do you have any allergies? If Yes, please identify below: __ Medicine __ Pollens __ Food __ Stinging Insects __ Others:

Yes

No

2.       Do you have any ongoing medical condition? If Yes, please identify below: __ Error of refraction __ Asthma __ Seizure __ Heart problem __ Anemia __ Bleeding disorder __ Hernia (painful bulge in the groin area) __ Others:

Yes

No

3.       Have you ever had surgery/ hospitalization? If Yes, please identify below:

Yes

No

Yes

No

4.       Does anyone in your family have the following conditions: __ Tuberculosis __ Cancer If yes, what kind? __ Stroke __ Diabetes Mellitus __ Hypertension __ Depression __ Others______________________________________ 5.       Exposure to cigarette/vape smoke at home?

I certify that the above information are correct.

Name & Signature of Parent/Guardian

Date

SHD Form 1-B

Name : ________________________________________

LRN : _______________________

Medical/Nursing Findings Grade 12/ SPED

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

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

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

Deworming (√ or X)

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

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: NS a. Normal Weight

Vision/ Auditory Screening Vision

Skin/Scalp a. Normal

Eye/Ear/Nose a. Normal

Mouth/Neck/Throat a. Normal

Heart/Lungs

Abdomen

a. Normal

a. Normal

Deformities a. Acquired (Specify)

b. Wasted/ Underweight

a. Passed L

R b. Presence of Lice

b. Inflamed Eye Lid b. Enlarged tonsils

b. Rales

b. Distended

c. Severely Wasted/Underwt

b. Failed

R c. Redness of Skin

c. Eye Redness

c. Presence of lesions

c. Wheeze

c. Abdominal Pain b. Congenital (Specify)

d. White Spots

d. Ocular Misalignment

d. Inflamed pharynx

d. Murmur

d. Tenderness

d. Overweight

L

Auditory

e. Obese

a. Passed L

R e. Flaky Skin

f. Normal Height

b. Failed

R f. Impetigo/boil

L

e. Pale Conjunctiva e. Enlarged lymphnodes

f. Matted Eyelashes

f. Others , specify

e. Irregular heart rate e. Dysmenorrhea

f. colds

g. Stunted

g. Hematoma

g. Eye Discharge

g. Cough

h. Severely Stunted

h. Bruises/ Injuries

h. Ear dischrage

h. Others, specify

i. Tall

i. Itchiness

i. Impacted cerumen

j. Skin Lessions

j. Mucus discharge

k. Acne/Pimple

k. Nose Bleeding (Epistaxis)

l. Capillary refill greater than 3 seconds

l. Others, specify

f. Others, Specify

m. others, specify Note: Use Letter to record ailments and Place X if not examined

SHD Form 1-C

Name : ____________________________________________

LRN : __________________________________

Medical Treatment Record Date

Chief Complaint

Intervention/Treatment Done

Remarks

Attended by (Name/Position)

2

SHD Form 1-D

Name : ____________________________________________

LRN : __________________________________ Dental Findings

Medical History

Guide Questions Yes

No

Remarks

Do you have a toothbrush?

Y

N

Allergy

How many times do you brush your teeth?

Asthma

How many times do you change your toothbrush in a year?

Anemia

Do you use toothpaste in brushing?

Bleeding problem

How many times do you visit the dentist in a year?

Health Ailment Diabetes Epilepsy Kidney Disease Convulsion Fainting

S.Y.

55 54 53 52 51 61 62 63 64 65

LEFT

PERMANENT TEETH

TEMPORARY TEETH

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

TEMPORARY TEETH

RIGHT

GRADE 2

RIGHT

PERMANENT TEETH

55 54 53 52 51 61 62 63 64 65

LEFT

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

TEMPORARY TEETH

85 84 83 82 81 71 72 73 74 75

LEFT

S.Y.

55 54 53 52 51 61 62 63 64 65

RIGHT

GRADE 3

LEFT

TEMPORARY TEETH

RIGHT

85 84 83 82 81 71 72 73 74 75

LEFT

S.Y.

55 54 53 52 51 61 62 63 64 65

LEFT

TEMPORARY TEETH

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

TEMPORARY TEETH

RIGHT

RIGHT

S.Y.

TEMPORARY TEETH

PERMANENT TEETH

RIGHT

GRADE 1

PERMANENT TEETH

KINDER

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

TEMPORARY TEETH

85 84 83 82 81 71 72 73 74 75

LEFT

RIGHT

85 84 83 82 81 71 72 73 74 75

LEFT

2

SHD Form 1-Da

Name : ____________________________________________

RIGHT

S.Y.

55 54 53 52 51 61 62 63 64 65

GRADE 5

LEFT

PERMANENT TEETH

TEMPORARY TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH

GRADE 6

S.Y.

55 54 53 52 51 61 62 63 64 65

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

TEMPORARY TEETH

85 84 83 82 81 71 72 73 74 75

LEFT

RIGHT

85 84 83 82 81 71 72 73 74 75

S.Y.

55 54 53 52 51 61 62 63 64 65

LEFT

ORAL HEALTH CONDITION Kinder

RIGHT

LEFT

TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

RIGHT

RIGHT

PERMANENT TEETH

GRADE 4

LRN : __________________________________

LEFT

1

7

2

8

3

9

4

10

5

11

6

12

Gingivitis Periodontal Disease

TEMPORARY TEETH

Malocclussion

PERMANENT TEETH

Supernumerary teeth 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Retained decidous teeth Decubital ulcer Calculus

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Cleft lip / palate Root fragment Fluorosis Others, Specify

TEMPORARY TEETH

RIGHT

85 84 83 82 81 71 72 73 74 75

LEFT

3

SHD Form 1-Db

Name : ____________________________________________ TEMPORARY TEETH Index d.f.t.

LRN : __________________________________

dft index Kinder

1

2

PERMANENT TEETH 3

4

5

6

Index D.M.F.T.

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

Kinder

1

7

2

8

3

9

4

10

5

11

6

12

Total Sound teeth

SYMBOL FOR MOUTH EXAMINATION X

- Carious tooth indicated for extraction

(ü)

-

Sound/erupted Permanent/Temporary tooth

FB

D

- Carious tooth indicated for filling

PFS

-

Pit and Fissure Sealant

CD - Complete Denture

RF - Root fragment

JC

-

Jacket Crown

GI

O

P

-

Pontic

SyF - Composite

RPD

-

Removable Partial Denture

AgF - Amalgan

- Missing tooth

F2 - Permanently filled tooth with

- Fixed Bridge - Glass Ionomer

recurrence of decay

Intervention/Treatment Record Date

Chief Complaint

Intervention/Treatment Done

Remarks

Attended by (Name/Position)