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Republic of the PhiliPPines

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

Date of Birth Region


Month Day Year

Birthplace Division
ParenUGuardian Telephone No.
Address
Pre-Ehm Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

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LL c LL C .E
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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

Mouth/Neck/Throat Lungs/Heart Abdomen/ Spine/ Remarks/


t{S SkinlScalp EyeslEar/Nose Genitalia Extremitiee lntervention
a. Normal Mouth a. Normal lungs a. Normal a- Normal a. Needs
a. Normal a. Normal a. Normal eye
Abdomen Snine Sr rnanricirir
b. Below b. Normal b. N. Upper b. Needs close
b. Pediculosis b. Normal ears b. Normal Throat b. Normal hearl
Genitalia Earemities supervision
Normal
c. Above c. Normal nose
c. Enlarged Tonsils c. Rales c. Mass c- N. Lower c. Needs
c. Tlnea Flava with/w/o exudates Extremities follow-uo
Normal
o. Ktnqworm d. 50urnilno d. LiO lesion cl. wheeze nemorrnoros d. Scoliosis d. Corrected
e. Eczema e. Pale e. lnflamed pharynx e. Murmur e. Tenderness e. Lordosis e. Treated
Conjunctiva with/do exudates
f. lmpetigo/ f. Ear discharge f. Enlarged lymph f. Deformed f. Genital f. Kyphosis f. Advised/
boil Chest Discharoe nnrrneclcd
g. Hematoma g. lmpacted g. Enlarged thyroid g. Distant heart g. Hernia g. Bowlegsi g. Referred
cerumen oland sounds knock knees
h. Bruises h. Septal h. Speech defect h. Irregular h. Others, h. Flat foot h. Parents
dcrriation heart rate sneeifi nntifiar{
i. Cuts/ i. Nasal i. kntal problem i. Others, i. Club foot i. Others,
Lacerations discharoe snecifu soecifv
j. Allergy j. Others, j. Others, specify j. Others,
cnarifrr
k. Others,
specify
Republic of the Philippines
Department of Education
Caraga Administrative Region
DIVISION OF SURIGAO DEL NORTE
Surigao City
SCHOOL HEALTH EXAMINATION CARD
Elementary Pupils

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
/ E o
CONDITION
Gingivitis
RIGHT

TEMPOMRYTEETH Periodontal Disease

Malocclusion
E
L Supermumentary
lr tooth
tu
F Retained deciducous
F
ztg l^
^lh
z
g Decubital Ulcer
tul
o- Calculus

Cleft lip/palate
CONDITION
TREATMENT Root fragment
NEEDS
TEMPORARYTEETH Fluorosis

RIGHT Others specify

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

Extraction No. T/decayed


Oral prophylaxis No. T/Missing
Referral No. T/filled
Other oral treatment Total D.M.F.T.
Total Sound Teeth

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