Department of Education

SCHOOLS DIVISION OFFICE

SCHOOL HEALTH EXAMINATION CARD
Name : Date of Birth :
Name of Parent/Guardian: ______ School : _________________________________
Address :
GRADE

KINDER I 2 3 4 5 6
DATE OF EXAMINATION
Weight (kg)
Height (cm.)
Nutritional Status
Vision
Hearing
Skin and Scalp
Eyes
Ears
Nose
Mouth
Throat
Neck
Heart
Lungs
Extremities
Other Illness
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. Observation
Injuries conjunctiva Teeth glands complex (specify)
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)
Family History

_____________ Hypertension
_____________ Asthma
_____________ Diabetes
_____________ Cancer (specify)
_____________ Tuberculosis
_____________ Kidney Disease
_____________ Liver Disease
_____________ Blood Dyscrasia
_____________ Allergy (specify)

Past Medical History

_____________ Previous Hospitalization

_____________ Previous Surgery
_____________ Other Diseases

Immunization History and Deworming

Date Given
__________ BCG _______________________________
__________ DPT _______________________________
__________ OPV _______________________________
__________ Measles _______________________________
__________ Hepa B _______________________________
__________ MMR _______________________________
__________ HPV _______________________________
__________ MR / TD _______________________________
__________ Deworming _______________________________

Date Chief Complaint Findings/Treatment

_____________________ _________________________ _________________________

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TEMPORARY TEETH PERMANENT TEETH
SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration SYMBOLS FOR ACCOMPLISHMENT

X – Carious tooth indicated for extraction F2 – permanently filled tooth JC – Jacket Crown P – Prophylaxis CF –
Cement filling
with recurrence of decay AB – Abutment X – Extracted permenent tooth ZnO – Zinc
Oxide Filling
F – Carious tooth indicated for filling Heavy Shade – Permanent filling P – Pontic xt – extracted temporary tooth
Corrected – correction of all
I - Inlay ag F – Amalgam filling / art defects
RF – Root Fragment Outline of Filling – Tooth wioth temporary RPD – Removable Partial Denture Sy F – Synthetic
Porcelein Filling TF – Treatment of eugenol in
O – missing tooth (√) Sound/erupted Permanent Tooth FB – Fixed Bridge R – Reffered to
private dentist
CD – Complete Denture