Sbip Forms 2019-2020

Name: LRN:
Kinder/ Grade 1/ Grade 2/ Grade Grade 4/ Grade 5/ Grade 6/ Grade Grade Grade 9/ Grade Grade
Grade Level 10/
SPED SPED SPED 3/ SPED SPED SPED SPED 7/ SPED 8/ SPED SPED 11/ SPED
SPED
Findings
Findings
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 Eye/Ear/Nose Mouth/Neck/Throat Lungs/Heart Abdomen Deformi
Screening
a. Normal Weight a. Passed a. Normal a. Normal a. Normal a. Normal a. Acquired
b. Wasted/ Underweight b. Failed b. Stye b. Enlarged tonsils b. Rales b. Distended b. Congenita
(Specify)
c. Severely c. Eye Redness c. Presence of lesions d. Wheeze c. Abdominal Pain
Wasted/Underwt
d. Overweight d. Ocular d. Inflamed pharynx e. Murmur d. Tenderness
Misalignment
e. Obese E. Pale e. Enlarged lymphnodes h. Irregular heart rate e. Dysmenorrhea
Conjunctiva
f. Normal Height f. Ear discharge f. Others , specify i. Others, f. Others, Specify
specify
g. Stunted g. Impacted
cerumen
h. Severely Stunted h. Mucus
discharge
i. Tall i. Nose Bleeding
(Epistaxis)
j. Eye dischrage
k. Matted
Eyelashes
l. Others , specify
Note: Use Letter to record ailments and Place X if not examined

SHD-Form 1-C
MEDICAL TREATMENT RECORD
Date Intervention/ Treatment Done Remarks Attended by( Name/Position)

Grade
12/ SPED
Findings
Deformities
cquired
ongenital
ecify)
osition)
School Based Immunization Program
Recording form 1: Masterlist of Enrolled Learners
Region: V (Bikol) Name of School: CARANAN SOUTH ELEMENTARY SC

Province/City: CAMARINES SUR Division: CAMARINES SUR
District/ Municipality: PASACAO Date:
To be filled up by Class Adviser
Date of Sex
Birth( MM/DD/YY Complete Age Immunization Stat
NO. Name of learner ( surname, first name, MI.) Address (Years) ( M/F) the number o
)
previously recei
learne
MCV
Prepared by:
NANCY L. IBARRIENTOS
School Health Coordinator
Noted:
EMENTARY SCHOOL Grade:
Section:
Name of Class Adviser:
Name of Supervisor/Principal: MICHAEL L. BANTA,EdD-CAR
ass Adviser
Immunization
unization Status ( Indicate Status( Complete for
the number of dozes age vsincomplete for with returned
eviously received by the age acknowlegdement and Consent for
learner consent form immunization given
Td HPV YES NO YES NO
MICHAEL L. BANTA,EdD-CAR
Principal I
Name of Vaccinator 1:
Name of Vaccinator 1:
Name of Recorder:
To be filled up by Vaccination team
History of allergy ( to Vaccine given in school Refussal

Sick today
prevoius immunization) or ( date:________________) /Deferral
presence of any contradiction
Yes No MCV Td HPV1 HPV2 HPV

To be filled up by Vaccination team
Vaccine given during community Refussal

Reason based map up immunization Reason
/Deferral
activity( date:________________)
MCV Td HPV1 HPV2

Republic of the Philippines Republic of the Philippines
DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION
Region V Region V
Division of Camarines Sur Division of Camarines Sur
Freedom Sports Complex San Jose Pili Camarines Sur Freedom Sports Complex San Jose Pili Camarines Sur
CARANAN SOUTH ELEMENTARY SCHOOL/112903 CARANAN SOUTH ELEMENTARY SCHOOL/112903
PERMISO SA PAGPURGA PERMISO SA PAGPURGA

Pinapayagan ko na magpapurga ang aking anak na si Pinapayagan ko na magpapurga ang aking anak na si
________________________________( Name of Pupil) base sa Kagawaran ________________________________( Name of Pupil) base sa Kagawaran
ng pang Edukasyon at Kalusugan para mapanatili ang ng pang Edukasyon at Kalusugan para mapanatili ang
kalusugan ng mga mag-aaral. kalusugan ng mga mag-aaral.
Lagda:_______________________________ Lagda:_______________________________
Magulang /Guardian Magulang /Guardian
4 P's 4 P's
Hindi 4 P's Hindi 4 P's
Region V Region V

Lagda:_______________________________ Lagda:_______________________________
4 P's 4 P's
Region V Region V

Lagda:_______________________________ Lagda:_______________________________
4 P's 4 P's
Region V Region V

ng pang Edukasyon at Kalusugan para mapanatili ang
Lagda:_______________________________ Lagda:_______________________________
4 P's 4 P's

Sbip Forms 2019-2020

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Sbip Forms 2019-2020

Caricato da

Copyright:

Formati disponibili

Name: LRN:

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

MEDICAL TREATMENT RECORD

Date Intervention/ Treatment Done Remarks Attended by( Name/Position)

Region: V (Bikol) Name of School: CARANAN SOUTH ELEMENTARY SC

To be filled up by Class Adviser

To be filled up by Vaccination team

History of allergy ( to Vaccine given in school Refussal

Yes No MCV Td HPV1 HPV2 HPV

Vaccine given during community Refussal

MCV Td HPV1 HPV2

PERMISO SA PAGPURGA PERMISO SA PAGPURGA

PERMISO SA PAGPURGA PERMISO SA PAGPURGA

PERMISO SA PAGPURGA PERMISO SA PAGPURGA

PERMISO SA PAGPURGA PERMISO SA PAGPURGA

Potrebbero piacerti anche