Appendix 11

TEACHER'S HEALTH CARD

Date:
Name: Date of Birth: Age: Gender: M F
School/District/Division: Civil Status S M W S
Position/Designation: Years in Service:
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 Mellitus [ ] [ ] Yellowish discoloration of skin/sclera [ ] [ ]
Cardiovascular Disease [ ] [ ] Last hospitalization (reason) [ ] [ ]
Allergy (pls. specify) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing: Others specify
ECG Neuropsychiatric exam:
Urinalysis Blood Typing:

Social History
 Appendix 11

Smoking Y N Age started: Sticks/packs per day: Packs 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 don: Y N if YES, When:
Self Breast examination done: Y N
Mass noted: Y N Specify where
For Male personnel: Digital rectal examination done: Y N Date examined:
Result:

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

Cough 2wks 1 month longer
Dizziness [ ] [ ] Lumps [ ] [ ]
Dyspnea [ ] [ ] Painful urination [ ] [ ]
Chest/Back pain [ ] [ ] Poor/loss of hearing [ ] [ ]
Easy fatigability [ ] [ ] Syncope/fainting [ ] [ ]
Joint/extremity pains [ ] [ ] Convulsions [ ] [ ]
Blurring of vission [ ] [ ] Malaria [ ] [ ]
Wearing eyeglasses [ ] [ ] Goiter [ ] [ ]
Vaginal discharge/bleeding [ ] [ ] Anemia [ ] [ ]
Dental Status: (pls. specify) Others: Pls. specify)
Present Medication taken: (pls. specify)

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

EXG - Electro Cardio Gram F - Full Term
Y - Yes P - Pre-mature
N - No A - Abortion
HPN - Hypertension L - Live Birth
CVD - Cardio Vascular Disease
DM - Diabetes Mellitus Interviewed by:
Date:
 Appendix 11

CONSULTATION AND TREATMENT RECORD:

Date/Signature of Treatment/
Chief Complaint Findings
Attending Physician Recommendation
Appendix 11
CS Form 86

HEALTH EXAMINATION RECORD

Name: Division: Department:
Date of Birth: Type of Work: Sex: Civil Status:

1 Date: Date: Date:

Height Height Height
Weight Weight Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: __________ Near: _________ With glasses: Far: __________ Near: _________ With glasses: Far: __________
Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________ Without glasses: Far: __________
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left: Right: Left:
CS Form 86

15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee's Signature:
Employee's Name (Print):
21 Physician's Signature:
Physician's Name (Print):
 CS Form 86

AMINATION RECORD

Civil Status:

Agility Test:

Far: __________ Near: _________

Far: __________ Near: _________
CS Form 86