TEACHER’S HEALTH CARD

Date:______________________________

Name: __________________________ Date of Birth: ______________ ____ Age: Gender: M F

School/District/Division: RAM ES/TUBAY-2/AGUSAN DEL NORTE Civil Status: __S M__ W

Position/Designation: TEACHER 1

First Year in Service:

Family History: (pls. Check) Y N Specify Relationship

Hypertension [ ] [ ] ______________________________

Cardiovascular Disease [ ] [ ] ______________________________

Diabetes Mellitus [ ] [ ] ______________________________

Kidney Disease [ ] [ ] ______________________________

Cancer [ ] [ ] ______________________________

Asthma [ ] [ ] _______________________________

Allergy [ ] [ ] _______________________________

Other Remarks:____________________________________________________________________________________

____________________________________________________________________________________

Past Medical History: (check)

Y N Y N

Hypertension [ ] [ ] Tuberculosis [ ] [ ]

Asthma [ ] [ ] Surgical Operations (pls. Specify) [ ] [ ]

Diabetes Melitus [ ] [ ] Yellowish discoloration of skin/sclera [ ] [ ]

Cardiovascular Disease [ ] [ ] Last hospitalization (reason) [ ] [ ]

Allergy (pls. Specify)_________________ Others (pls. Specify)_________________________

Last Taken Date Result Date Result

CXR/Sputum Result: _______ ________ Drug Testing: ________ _______ Others: specify_________

ECG _______ ________ Neuropsychiatric exam: _________ _______

Urinalysis _______ _______ Blood Typing: ________ _______

Social History

Smoking Y_____ N______ Age Started:____________ Sticks/ packs per day:_______ Pack per year:________

Alcohol Y_____ N______ How often: _____________ Food preference: __________

OB Gyn History (pls. Encircle) (Female Teachers)

Menarche __________ Cycle____________ Duration _______________

Parity: F P A L

Papsmear done: Y N if YES, when:___________________

 Self Breast examination done: Y N Specify where:_________________

Mass noted: Y N

For Male personnel: Digital rectal examination done: Y N Date examined:__________

Result:_____________________

Present Health Status (pls. Check) Y N Y N

Cough 2wks 1month longer [ ] [ ] Lumps [ ] [ ]

Dizziness [ ] [ ] Painful urination [ [ [ ]

Dyspnea [ ] [ ] Poor/loss of hearing [ ] [ ]

Chest/Back pain [ ] [ ] Syncope/fainting [ ] [ ]

Easy fatigability [ ] [ ] Convulsions [ ] [ ]

Joint/extremity pains [ ] [ ] Malaria [ ] [ ]

Blurring of visions [ ] [ ] Goiter [ ] [ ]

Wearing eyeglasses [ ] [ ] Anemia [ ] [ ]

Vaginal discharge/bleeding [ ] [ ] Others: (pls. Specify [ ] [ ]

Dental Status: (pls. Specify) _______________________________

Present medication taken: (pls. Specify)________________________________________________________________

Legend: CXR -Chest X- ray PTB -Pulmonary Tuberculosis

ECG -Electro-Cardio Gram F -Full Term

Y -Yes P -Pre - mature

N -No A -Abortion

HPN -Hypertension L -Live Birth

CVD -Cardio vascular Disease

Interviewed by:___________________

Date:

CONSULTATION AND TREATMENT RECORD

Date/Signature of Chief Complaint Findings Treatment/

Attending Physician
Reccomendation