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Department of Education
Davao City
SCHOOL HEALTH EXAMINATION CARD
Name : Region/Division :
Date of Birth : Address :
Name of Parent/Guardian : School Address:
GRADE / YEAR IMMUNIZATION RECEIVED AND
PRE-ELEM I II III IV V VI
DATE GIVEN
DATE OF EXAMINATION
Weight (kg)
Height (cm.)
Vision (Snellen's Chart)
Hearing
Nutritional Status
Skin and Scalp
Eyes
Ears
Nose
Mouth
Throat
Neck
Heart
Lungs
Extremities
Other Illness (identify)
Remarks
Examined by
Skin & Scalp Eyes & Ears Nose & Throat & Neck Heart & Lungs Extremities Nutritional Remarks
Mouth Status
a. Pediculosis a. Granular a. a. Enlarged a. Normal a. Abnormal a. Normal a. Referred
b. Tinea Flava eyelids Colds/cough tonsillitis b. RF / RHD b. Deformities b. Mild b. Treated
c. Scabies b. Inflamed eyes b. Dirty b. Inflamed c. CVD (Conginital or c. Moderate c. Further
d. Ulcers c. Squinting Eyes Teeth throat d. Asthma Acquired) d. Severe Evaluation
e. Minor d. pale c. Defective c. Enlarged e. Primary c. Others e. Overweight d.
Injuries conjunctiva Teeth glands complex (specify) OPbservation
f. Ringworm e. Discharging d. Stomatitis d. Goiter f. Others
g. Skin Allergy Ears e. Cleft e. Others (specify)
h. Others f. Impacted palate (specify)
(specify) cerumen f. Harelip
g. Others g. Defective
(Specify) Speech
h. Others
(specify)
Note: Use letter to record ailments
Republic of the Philippines
Department of Education
Pasig City