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Department of Educatisn
Caraga Admin istrative Region
DU|SMN OF SURIGAO DEL NORTE
Sur(Xao City
SCHOOL HEALT+I EXAilIINATION CARD
ElementaryPuPils
NAME: SCHOOL
First Middle
Birthplace Division
ParenUGuardian Telephone No.
Address
Pre-Ehm Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6
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Date of Examination
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Heiqht
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/Nose
Mouth/ThroaUNeck
Lrrnos/Heart
Abdomen/Genitalia
Spiner'Extremities
Others, specify
Examined by
MEDICAL HISTORY
YES NO Guide Questions
Ailergy
Asthm, Do you have a toothbrush? Y N
Anemia
How many times do you brush your teeth? Once 2x 3x
Bleedino Problem
- -
Heart ailment
- -
How many times do you change your toothbrush in a year?
Diabetes
EDileosv Do you use toothpaste in brushing? Y N
Kidncv disease
Cnnrrr rlcinn
How many times do you visit the dentist in a year? once _2x
Faintinq
-
-
ORAL HEALTH CONDITION
CONDITION AND TREATMENT NEEDS Pre-Schooler 1
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CONDITION
Gingivitis
RIGHT
Malocclusion
E
L Supermumentary
lr tooth
tu
F Retained deciducous
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g Decubital Ulcer
tul
o- Calculus
Cleft lip/palate
CONDITION
TREATMENT Root fragment
NEEDS
TEMPORARYTEETH Fluorosis
CONDITION
DENTAL PROCEDURES
TEMPORARY TEETH DATE OF VISITS
lndex: d.f.t. Pre-schooler 1 2 3 4 5 6
Pre-schooler 1 2 3 4 5 6 Remarks No. T/decayed
DATE
No. T/filled
Examination
Total d.f.t.
Sealant (G.1.)
Gum Treatment PERMANENT TEETH DATE OF VISITS
Permanent fillino
ART lndex: D.M.F.T. Pr+schooler 2 3 4 5 6