School Health Examination Card: Bureau of Learner Support Services - School Health Division

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/
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED
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
Screening
a. Normal a. Passed a. Normal a. Normal a. Normal a. Normal a. Normal
Weight
b. Wasted/ b. Failed b. Presence of Lice b. Stye b. Enlarged tonsils c. Rales b. Distended
Underweight
c. Severely c. Redness of Skin c. Eye Redness c. Presence of lesions d. Wheeze c. Abdomnial Pain
Wasted/Underwt
2018 SHD Form 2
d. Overweight d. White Spots d. Ocular d. Inflamed pharynx e. Murmur d. Tenderness
Misalignment
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
k. Acne/Pimple k. Matted Eyelashes
Note: Use Letter to record ailments and Place X if not examined

2018 SHD Form 2
OF THE PHILIPPINES
NT OF EDUCATION
SERVICES - SCHOOL HEALTH DIVISION
SION OF CEBU PROVINCE
EXAMINATION CARD
Grade 10/ Grade 11/ Grade 12/

SPED SPED SPED
Findings
Findings
Findings
Abdomen Deformities
a. Normal a. Acquired
b. Distended b. Congenital
(Specify)
c. Abdomnial Pain
2018 SHD Form 2
d. Tenderness
e. Dysmenorrhea
f. Others, Specify
2018 SHD Form 2
INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention/Treatment Done Remarks
SCHOOL ORAL HEALTH EXAMINATION CARD
KINDER S.Y. GRADE 1
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53

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
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
2
PERMA
PERMA
2018 SHD Form 2
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83
GRADE 2 S.Y. GRADE 3
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13
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
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83
2
2018 SHD Form 2
Attended by
Remarks (Name/Position)
N CARD
S.Y.
52 51 61 62 63 64 65 LEFT
12 11 21 22 23 24 25 26 27 28
42 41 31 32 33 34 35 36 37 38
2
2018 SHD Form 2
82 81 71 72 73 74 75 LEFT
S.Y.
52 51 61 62 63 64 65 LEFT
12 11 21 22 23 24 25 26 27 28
42 41 31 32 33 34 35 36 37 38
82 81 71 72 73 74 75 LEFT
2
2018 SHD Form 2
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14
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
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14
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
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54
3
2018 SHD Form 2
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14
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
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14
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
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84
3
2018 SHD Form 2
S.Y.
53 52 51 61 62 63 64 65 LEFT
13 12 11 21 22 23 24 25 26 27 28
43 42 41 31 32 33 34 35 36 37 38
83 82 81 71 72 73 74 75 LEFT
S.Y.
53 52 51 61 62 63 64 65 LEFT
13 12 11 21 22 23 24 25 26 27 28
43 42 41 31 32 33 34 35 36 37 38
83 82 81 71 72 73 74 75 LEFT
S.Y.
53 52 51 61 62 63 64 65 LEFT
3
2018 SHD Form 2
13 12 11 21 22 23 24 25 26 27 28
43 42 41 31 32 33 34 35 36 37 38
83 82 81 71 72 73 74 75 LEFT
S.Y.
53 52 51 61 62 63 64 65 LEFT
13 12 11 21 22 23 24 25 26 27 28
43 42 41 31 32 33 34 35 36 37 38
83 82 81 71 72 73 74 75 LEFT
3
2018 SHD Form 2
GRADE 12 S.Y. ORAL HEALTH CO
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

Index d.f.t. Kinder 1 2 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
Total Sound teeth
SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent tooth
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant
RF - Root fragment JC - Jacket Crown
M - Missing tooth PFS - Pontic
F2 - Permanently filled tooth with RPD - Removable Partial Denture
recurrence of decay
2018 SHD Form 2
INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention/Treatment Done Remarks

2018 SHD Form 2
ORAL HEALTH CONDITION
1 2 3 4 5 6
Kinder 7 8 9 10 11 12
1 2 3 4 5 6
Kinder 7 8 9 10 11 12
FB - Fixed Bridge
CD - Complete Denture
GI - Glass Ionomer
CO - Composite
AM - Amalgan
2018 SHD Form 2
Remarks Attended by (Name/Position)

Republic of the Philippines
Department of Education Appendix 11
Region VII, Central Visayas
Division of Cebu Province
District of Liloan
TEACHER'S HEALTH CARD
Date:
Name: Date of Birth: Age: Gender:
School/District/Division: Civil Status
Position/Designation: Years in Service:
First Year in Service:
Family History: (pls. check) Y N Specify Relationship

Hypertension [ ] [ ]
Cardiovascular Disease [ ] [ ]
Diabetes Mellitus [ ] [ ]
Kidney Disease [ ] [ ]
Cancer [ ] [ ]
Asthma [ ] [ ]
Allergy [ ] [ ]
Other Remarks:
Past Medical History: (check)

Y N
Hypertension [ ] [ ] Tuberculosis
Asthma [ ] [ ] Surgical Operations (pls. specify)
Diabetes Mellitus [ ] [ ] Yellowish discoloration of skin/sclera
Cardiovascular Disease [ ] [ ] Last hospitalization (reason)
Allergy (pls. specify) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing:
ECG Neuropsychiatric exam:
Urinalysis Blood Typing:
Social History
Smoking Y N Age started: Sticks/packs per day:
Alcohol Y N How often: Food preference:
OB Gyn History (pls. encircle) (Female Teachers)

Menarche: Cycle Duration
Parity: F P A L
Papsmear don: Y N if YES, When:
Self Breast examination done: Y N
Mass noted: Y N Specify where
For Male personnel: Digital rectal examination done: Y N
District of Liloan
Present Health Status (pls. check) Y N
Cough 2wks 1 month longer
Dizziness [ ] [ ] Lumps
Dyspnea [ ] [ ] Painful urination
Chest/Back pain [ ] [ ] Poor/loss of hearing
Easy fatigability [ ] [ ] Syncope/fainting
Joint/extremity pains [ ] [ ] Convulsions
Blurring of vission [ ] [ ] Malaria
Wearing eyeglasses [ ] [ ] Goiter
Vaginal discharge/bleeding [ ] [ ] Anemia
Dental Status: (pls. specify) Others: Pls. specify)
Present Medication taken: (pls. specify)
Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis

EXG - Electro Cardio Gram F - Full Term
Y - Yes P - Pre-mature
N - No A - Abortion
HPN - Hypertension L - Live Birth
CVD - Cardio Vascular Disease
DM - Diabetes Mellitus Interviewed by:
Date:
District of Liloan
Gender: M F
Civil Status S M W S
Years in Service:
Relationship
Y N
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
Others specify
Packs per year:
Date examined:
Result: Division of Cebu Province
District of Liloan
Y N
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
Appendix 11
CONSULTATION AND TREATMENT RECORD:

Date/Signature of Treatment/
Chief Complaint Findings
Attending Physician Recommendation
Appendix 11
CS Form 86 Department of Education
District of Liloan
HEALTH EXAMINATION RECORD

Name: Division:
Date of Birth: Type of Work:
1 Date: Date:
Height Height
Weight Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: __________ Near: _________ With glasses: Far: __________ Near: ________
Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: ________
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee's Signature:
Employee's Name (Print):
21 Physician's Signature:
Physician's Name (Print):
CS Form 86 Department of Education
District of Liloan
AMINATION RECORD
Department:
Sex: Civil Status:
Date:
Height
Weight
Sitting: Agility Test:
Near: _________ With glasses: Far: __________ Near: _________

Near: _________ Without glasses: Far: __________ Near: _________
Right: Left:
DEPARTMENT OF EDUCATION
Region:
Division of:
DENTAL REFERRAL FORM
Patients Name:
Age:
Phone Number:
Dear Dr.:
I am referring to your office for:
Oral Prophylaxis
Restoration 18 17 16 15 14 13 12 11 21
47 47 46 45 44 43 42 41 31
Extraction
Other Procedures:
Note: (Example: Resto#16, Exo #46) If OUT is needed
Sincerely:
School Dentist
Kindly return Dental Slip
DENTAL TREATMENT RETURN SLIP
Dental Procedure done:
Oral Prophylaxis
Restoration
Extraction
Other Procedures:
Signature:
DENTIST'S NAME:
Lic. No.:
HNC Form 5

Department of Education
Region ____________________
Division of __________________________
REFERRAL SLIP
To Date
(Agency)
Address
This is to refer to you:
Name: Age: Sex:

Address/School: Grade:
Chief Complaint:
Impression:
Remarks:
Name and Signature
Designation
Note: To be detached from upper portion and sent back to the school.
Return Slip
Returned to
Name of Patient Date Referred
Chief Complaint
Findings
Action/Recommendations
HNC Form 5
Date Name & Signature
Designation
HNC Form 5
Signature
ation
HNC Form 5
ignature
ation
Appendix 6
HNC NS Form 1
Region ___________________
DIVISION OF CEBU PROVINCE
______________________________________________
School Name/ID
RECORD OF DAILY TREATMENT
Chief
Date Name of Patient Grade Treatment Attended
Complaint
Name
Appendix 6
HNC NS Form 1
ttended by Signature of Patient Remarks
Designation
Appendix 8
HNC NS Form 3
Region _______________________
Division of ____________________
ANNUAL/MONTHLY HEALTH SERVICES ACCOMPLISHMENT REPORT

SY: ________________________
Name of School: School ID No.:
Total No. of Elem. Schools Visited

Total No. of Sec. Schools Visited
I. General Information
A. School Enrolment
1. Male
2. Female
B. No. of School Personnel
1. Teaching
Male
Female
2. Non-Teaching
Male
Female
II. Health Services
A. Health Appraisal
1. No. of Assessed:
a. Learners
b. Teachers
c. NTP
2. No. with Health Problems
a. Learners
b. Teachers
c. NTP
3. No. of Vision Screening (Learners)
B. Treatment Done
Appendix 8
a. Learners
b. Teachers
c. NTP
Appendix 8
C. No. of Pupils Dewormed

1st Round
2nd Round
D. No. of Pupils Given Iron Supplement
E. No. of Pupils Immunized (Specify vaccine given)
F. No. of consultation attended
1. Learners
2. Teachers
3. NTP
G. Referral (No. Referred to)
1. Physician
2. Dentist
3. Guidance
4. Other facilities
5. RHU/ District/ Provincial Hospital
III. Health Education
No. of Classes given health lectures:
A. No. of orientation training conducted to:
1. Learners
2. Teachers
3. Parents
4. Others (Specify)
B. No. of conferences/meeting with:
1. Teachers/ Adminstrators
2. Health officials
3. Learners
4. Parents
5. LGU/Barangay
6. NGO's/Stakeholders
C. Involvement as Resource Person/ Consultant/ Adviser/ Judge
1. Health Activities/ programs/ contests
2. Class Discussion
3. Health Clubs/ Organization
IV. School Community Activities for Health and Nutrition
A. PTA/ Homeroom Organization Meetings
Appendix 8
B. Parent Education Seminar/ Workshop/Training

C. Home Visits Conducted
D. Hospital Visits made
Appendix 8
V. Common Signs & Symptoms

A. Skin and Scalp
1. Presence of Lice (Pediculosis)
2. Redness of Skin
3. White Spots
4. Flaky Skin
5. Minor Injuries
6. Impetigo/Boil
7. Skin Lessions
8. Acne/Pimples
9. Itchiness
B. Eye and Ears
1. Matted eye lashes
2. Eye redness
3. Ocular misalignment (Squint)
4. Eye dischrge
5. Pale conjunctiva
6. Hordeolum
7. Ear discharge
8. Mucos discharge
9. Nose bleeding (epistaxis)
C. Mouth/ Neck / Throat
1. Presence of Lessions
2. Inflammed Pharynx
3. Enlarged tonsils
4. Enlarged lymphnodes
D. Heart and Lungs
1. Rates
2. Murmur
3. Irregular heart rate
4. Wheezes
E. Deformities
1. Acquired (Specify)
2. a. Acquired
Appendix 8
F. Nutritional Status
a. Normal
b. Wasted
c. Severly Wasted
d. Obeese
e. Overweight
f. Stunted
g. Tall
G. Abdomen
1. Abdominal pain
2. Distended
3. Tenderness
4. Dysmenorrhea
H. Dental Service
1. Gingivitis
2. Periodontal Disease
3. Malocclussion
4. Supernumecoary Teeth
5. Retained decidous Teeth
6. Decubital Ulcer
7. Calculus
8. Cleff Lip/ Palate
9. Flourosis
10. Others / Specify
11. Total # of DMFT
12. Total # of dmft
I. Other Signs & Symptoms Noted:
1.
2.
3.
4.
5.
6.
7.
8.
Appendix 8
9.
10.
Appendix 8
VI. Remarks:
Prepared by: Noted by:
Name / Designation SECTION HEAD
Date
Appendix 9
HNC NS Form 4
Region _______________________
Division of ____________________
School Health Survey

Year _________
Name of School District:

Address School ID
Name of School Head Contact No.:
I. General Information
1. Enrollment:
Male Female Total
A. Elementary
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
SPED
Total
B. Junior HS
Grade 7
Grade 8
Grade 9
Grade 10
Senior HS
Grade 11
Grade 12
SPED
ALS Learners
Total
2. School Personnel
Male Female Total

Teaching
Non-Teaching
Total
3. Number of Drop-out due to:
Male Female Total

Appendix 9
a. Illness
b. Poverty
c. Other reasons
II. Health Profile

1. Number Examined/Assessed: Male Female Total
a. Learners
b. Teachers
c. NTP
2. Found with:
a. Health Problems
b. Physical deformities/defects
1.
2.
3.
3 Treated
1.
2.
3.
4 Number dewormed
5 No. given Iron Supplement
6 Number referred to other facilities
7 Number referred to
a. Physicians
b. Dentist
c. Nurse
d. Guidance Counselors
e. Others
B. Ten Common Signs and Symptoms noted:
Learners Teaching & NTP

Signs & Symptoms No. of Cases Rank Signs & Symptoms No. of Cases Rank
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
III. School Facilities

1. School site area sq. meters
2. Number of buildings
3. Number of classrooms
4. Health facilities
1. School Clinic
a. Area sq. meters
Appendix 9
b. Location (Please check)

separate building
room within the building
within a classroom/room
Appendix 9
c. Provision and maintenance (Please check)

toilet in the clinic
potable water supply
medicines
weighing scale (specify)
height stadiometer
medicine/treatment cabinet
examination table/bed
foot stool/receptacle
dental chair
potable water supply
working table
treatment records
clinic teacher/school nurseassigned
stock cabinet
2. School Toilet
a. Provision of gender sensitive type toilet
b. Number of seats/urinal
c. Provision of menstrual hygiene room
d. Availability of sanitary pad
3. Water supply and drinking water
a. Source
b. Certificate of Water analysis
4. Washing Facilities
a. Source
b. provision of handwashing soap
5. School Canteen
a. Sanitary Permit
b. Health Certificate of helpers
c. Compliance to DepEd Order No. 13, s. 2017
Remarks:
Accomplished by:
Name
Designation
Date of Survey
NOTE: to be accomplished once every 3 years

School Health Examination Card: Bureau of Learner Support Services - School Health Division

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School Health Examination Card: Bureau of Learner Support Services - School Health Division

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Formats disponibles

2018 SHD Form 2

REPUBLIC OF THE PHILIPPINES

SCHOOL HEALTH EXAMINATION CARD

Name: School ID:

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

k. Acne/Pimple k. Matted Eyelashes

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

Grade 10/ Grade 11/ Grade 12/

Date Chief Complaint Intervention/Treatment Done Remarks

SCHOOL ORAL HEALTH EXAMINATION CARD

KINDER S.Y. GRADE 1

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53

TEMPORARY TEETH TEMPORARY TEETH

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

GRADE 2 S.Y. GRADE 3

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53

TEMPORARY TEETH TEMPORARY TEETH

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

GRADE 4 S.Y. GRADE 5

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54

TEMPORARY TEETH TEMPORARY TEETH

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

GRADE 6 S.Y. GRADE 7

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54

TEMPORARY TEETH TEMPORARY TEETH

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

GRADE 8 S.Y. GRADE 9

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54

TEMPORARY TEETH TEMPORARY TEETH

TEMPORARY TEETH TEMPORARY TEETH

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

GRADE 10 S.Y. GRADE 11

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54

TEMPORARY TEETH TEMPORARY TEETH

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

GRADE 12 S.Y. ORAL HEALTH CO

TEMPORARY TEETH dft index PERMANENT TEETH

SYMBOL FOR MOUTH EXAMINATION

Date Chief Complaint Intervention/Treatment Done Remarks

ORAL HEALTH CONDITION

Remarks Attended by (Name/Position)

TEACHER'S HEALTH CARD

Family History: (pls. check) Y N Specify Relationship

Past Medical History: (check)

OB Gyn History (pls. encircle) (Female Teachers)

Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis

Packs per year:

CONSULTATION AND TREATMENT RECORD:

HEALTH EXAMINATION RECORD

Sitting: Agility Test:

Near: _________ With glasses: Far: __________ Near: _________

I am referring to your office for:

Note: (Example: Resto#16, Exo #46) If OUT is needed

Kindly return Dental Slip

DENTAL TREATMENT RETURN SLIP

Dental Procedure done:

Republic of the Philippines

This is to refer to you:

Name: Age: Sex:

Name and Signature

Date Name & Signature

RECORD OF DAILY TREATMENT

ttended by Signature of Patient Remarks

Near: _ With glasses: Far: Near: ___