Republic of the Philippines

Department of Education
City Schools Division of Antipolo

ANTIPOLO CITY SENIOR HIGH SCHOOL

DISTRICT I-A

I.PERSONAL INFORMATION
Name: ______________________________________________________________
Picture
Last Name Given Name Middle Name Suffix
1x1
Address: _____________________________________________________________
______________________________________________________________
Grade: __________
Contact Number: ___________________________ Gender: ____ Age: ____
Track: ___________
Birthday: ________/______/______ Birthplace: ___________________ Section:__________
Month Day Year
LRN No: _________
Parents/Guardian: Relationship:

Contact Number:
II. MEDICAL HISTORY III. FAMILY MEDICAL HISTORY

Date of Last Medical Exam: ____________________________ Blood Type:_______ Have anyone on your family have been clinically diagnosed any of the
following?
Last Menstruation Period:_______________________(for girls only) (Please Check the Appropriate Answer)
YES NO REMARKS
Have you ever been hospitalized? ______ Yes _______ No
Heart
If YES:
Date: Reason Hospital Lungs

___________ ____________________________ _________________ Hypertension

Nervous
___________ ____________________________ __________________
Digestive
___________ ____________________________ __________________ Endocrine
Are you taking any medications? ______ Yes _______ No Skin
If YES:
Liver
List the Medications:
______________________________ Hearing
______________________________
______________________________ Vision
______________________________ Blood

Do you have Allergies? (Food/Medications/Latex) ______ Yes _______ No Kidney

If YES
______________________________
Others:
______________________________
______________________________
_________________________________
______________________________ _________________________________

Immunization: (for the Last 5 years) ______ Yes _______ No

If YES IV. CONSENT
______________________________
______________________________
______________________________
______________________________
I,_____________________________, ___________.
Name of Parent/Guardian Years of Age
Have you ever been clinically diagnosed of the following problem/s?
Legal guardian of____________________________,
(Please Check the Appropriate Answer)
Name of Student
YES NO REMARKS
Heart
voluntarilygive my consent on rendering physical
examination/check up by the authorized member
Lungs
of Department Education Medical Staff. And
Hypertension
hereby attest that all the information checked and
Nervous written are true and correct.
Digestive
Endocrine ________________________
Signature Over Printed Name
Skin
Liver Date and Time: _________________

Hearing Witness:
Vision ________________________
Signature Over Printed Name
Blood
Kidney Date and Time: _________________

Others
 Republic of the Philippines
Department of Education
City Schools Division of Antipolo

ANTIPOLO CITY SENIOR HIGH SCHOOL

DISTRICT I-A

V. PHYSICAL EXAM
(To be accomplish by DepEd Medical Staff)

GRADE 11 GRADE 12
First Semester Second Semester First Semester Second Semester

Intervention

Intervention

Intervention

Intervention
Findings

Findings

Findings

Findings
Date of Examination
Temperature / BP
Heart/ Respiratory/
Pulse Rate
Height
Weight
Nutrition Status (NS)
Height for Age
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,
c. AbN Rt, d. AbN Lf
Skin / Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen/Genitalia
Spine/Extremities
Others, specify
Examined by

Mouth/Throat/ Abdomen/ Spine/ Remarks /

NS Skin/Scalp Eyes/Ears/Nose Lungs/Heart
Neck Genitalia Extremities Intervention
a. Normal a. Normal a. Normal a. Normal a. Normal a. Normal a. Normal a. Normal

b. Severely Wasted b.Pediculosis b.Squinting b.Enlarged b.Deformed b. Mass b. Scoliosis b.Needs

Lymph Nodes Chest Supervision

c. Wasted c.Tinea Flava c.Pale c. Lip Lesion c.Irregular c. Tenderness c. Lordosis c.Needs
Conjunctivae Rhythm Follow up
d. Overweight d.Ringworm d.Red d.Enlarged d.Tachycardia d.Genital d.Kyphosis d.Corrected
Conjunctivae Tonsils Disharge
e. Obese e.Eczema e.Ear Discharge e.Inflamed e.Bradycardia e. Hernia e. Bowlegs e. Treated
Pharynx
f. Severely Obese f.Impetigo / Boil f. Impacted f.Enlarged f.Distant Heart f.Others, f.Knock f.Advised
Cerumen Thyroid Gland Sounds Specify Knees /Counseled
g.Hematoma g. Septal g. Speech g.Rales g.Club Foot g.Referred
Deviation Defect
h.Bruises h. Nasal h.Dental h.Wheeze h.Others, h. Parents
Discharge Problem Specify Notified
i.Cuts/ i.Others,Specify i. Others,Specify i.Murmur i.Others,
Lacerations Specify
j.Allergy j.Others,Specify

k.Others,Specify

Remarks:

IRMA P. TALAVERA, RN.

SHS – NURSE II