School Health Examination Card for Elementary.pdf

Republic of the PhiliPPines Department of Educatisn Caraga Admin istrative Region DU|SMN OF SURIGAO DEL NORTE Sur(Xao City SCHOOL HEALT+I EXAilIINATI
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  NAME:Republic of the PhiliPPinesDepartment of Educatisn Caraga Admin istrative Region DU|SMN OF SURIGAO DEL NORTE Sur(Xao City SCHOOL HEALT+I EXAilIINATION CARD ElementaryPuPils SCHOOL Middle Region Year DivisionTelephone No. First Date of Birth MonthDay Birthplace ParenUGuardian Address Pre-Ehm Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 o) .g o .= LL .9 c o a o c o, .E U .s LL E .9 c o z o C o) .c p .E lr C .9 E 0) z o) C o) .E E .E LL c .o C o) a (I) c o) .E o .E LL C .9 c o a 0, c ct) .E T c i.r- c .9 c o e o C o) E .c LL C .a c o z o c Date of ExaminationTemperature/BPHeart Rate/Pulse Rate/Respiratory RateHeiqht Wehht Nutritional Status (NS) Visual Acuity (Snellen s)a. N Rt, b. N Lf, c. AbN Rt, d. AbN Lf Hearing (Tuning Fork)a. N Rt, b. N Lf, o..AbN Rt, d. AbN Lf Skin/Scalp Eyes/Ears/NoseMouth/ThroaUNeckLrrnos/HeartAbdomen/GenitaliaSpiner Extremities Others, specify Examined byt{S SkinlScalpEyeslEar/NoseMouth/Neck/Throat Lungs/Heart Abdomen/ Genitalia Spine/ExtremitieeRemarks/ lntervention a. Normal a. Normala. Normal eye a. Normal Moutha. Normal lungs a. Normal Abdomen a- NormalSnine a. Needs Sr rnanricirir b. BelowNormalb. Pediculosis b. Normal earsb. Normal Throat b. Normal hearl b. Normal Genitalia b. N. UpperEaremitiesb. Needs close supervision c. Above Normalc. Tlnea Flavac. Normal nose c. Enlarged Tonsils with/w/o exudatesc. Rales c. Mass c- N. Lower Extremitiesc. Needsfollow-uo o. Ktnqwormd. 50urnilno d. LiO lesion cl. wheeze nemorrnorosd. Scoliosis d. Corrected e. Eczema e. PaleConjunctiva e. lnflamed pharynx with/do exudates e. Murmur e. Tenderness e. Lordosis e. Treated f. lmpetigo/ boil f. Ear discharge f. Enlarged lymph f. DeformedChest f. Genital Discharoe f. Kyphosis f. Advised/ nnrrneclcd g. Hematomag. lmpactedcerumen g. Enlarged thyroid oland g. Distant heartsoundsg. Hernia g. Bowlegsiknock knees g. Referred h. Bruisesh. Septaldcrriationh. Speech defect h. Irregular heart rate h. Others, sneeifi h. Flat foot h. Parentsnntifiar{ i. Cuts/ Lacerations i. Nasal discharoe i. kntal problem i. Others,snecifu i. Club footi. Others, soecifv j. Allergy j. Others, j. Others, specify j. Others,cnarifrr k. Others, specify  Republic of the PhilippinesDepartment of Education Caraga Administrative Region DIVISION OF SURIGAO DEL NORTESurigao City SCHOOL HEALTH EXAMINATION CARD Elementary Pupils MEDICAL HISTORY CONDITIONRIGHT TEMPOMRYTEETH CONDITION TREATMENT NEEDS TEMPORARYTEETH RIGHTCONDITION E L lr tu FF z tg z g t ul o- Guide Questions Do you have a toothbrush? Y - N How many times do you brush your teeth? - Once - 2x - 3x How many times do you change your toothbrush in a year?Do you use toothpaste in brushing? Y - N How many times do you visit the dentist in a year? - once _2x TEMPORARY TEETH DATE OF VISITSlndex: d.f.t.No. T/decayed No. T/filled Total d.f.t. PERMANENT TEETH DATE OF VISITS lndex: D.M.F.T. No. T/decayedNo. T/Missing No. T/filled Total D.M.F.T. Total Sound Teeth YES NO Ailergy Asthm, AnemiaBleedino ProblemHeart ailmentDiabetes EDileosv Kidncv disease Cnnrrr rlcinn Faintinq CONDITION AND TREATMENT NEEDS ORAL HEALTH CONDITION Pre-Schooler 1 / E o Gingivitis Periodontal Disease MalocclusionSupermumentary toothRetained deciducous l^ ^lh Decubital UlcerCalculusCleft lip/palate Root fragmentFluorosis Others specify DENTAL PROCEDURES Pre-schooler 1 234 5 6 Remarks DATE ExaminationSealant (G.1.) Gum TreatmentPermanent fillino ART Extraction Oral prophylaxis ReferralOther oral treatment Pre-schooler 1 2 3 45 6 Pr+schooler 2 345 6
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