Name: _____________________________________________ LRN:____________________________________

KINDER/S GRADE 1/ GRADE GRADE 3 GRADE 4 GRADE GRADE GRADE GRADE GRADE GRADE GRADE GRADE
PED SPED 2 /SPED /SPED SPED 5 /SPED 6 /NSPED 7 / SPED 8 /SPED 9 /SPED /10 11 12
SPED /SPED /SPED

FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS
Date of Examination

Height (in cm)

Weight ( in kg)
Nutritional Status(NS) (BMI/Wt-for –age)

Nutritional Status(NS) (height /Wt-for –

age)
4Ps Beneficiary

SBFP Beneficiary
Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul
Deworming
Iron Supplementation

Immunization (specify what kind)

Menarche
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate

Vision Screening using Appropriate Chart

Auditory Screening(Tuning Fork)

Skin/Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck

Lungs/Heart
Abdomen
Deformities
Others,specify

EXAMINED BY:___________________________________ DESIGNATION: ________________________________________

LEGEND:

NS VISION/AUDITORY SKIN/SCALP EYE/EAR/NOSE MOUTH/NECK/THROA HEART/LUNGS ABDOMEN DEFORMITIES

SCREENING T
a.Normal Vision a.Normal a.Normal a.Normal a.Normal a.Normal a. Acquired
Weight (Specify)
a.Passed L R b.Presence of b.Inflamed eye lid b.Enlarge tonsils b. Rales b. Distended
lice
b.Severely b.Failed L R c. Redness of c.Eye redness c.Presence of Lesions c. Wheeze c. Abdominal b. Congenital
wasted/underw Skin pain (Specify)
t
d.Overweight Auditory d.White Spots d.Ocular d.Inflamed pharynx d. Murmur d. Tenderness
e.Obese a.Passed L R e.Flaky Skin e.Pale Conjunctiva e.Enlarge Lymphnodes e. Irregular e.
Heart rate Dysmenorrhea
f.Normal height b.Failed L R f.impetigo/boil f.Matted f. Others, Specify f. Colds f. Others,
eyelashes Specify
g.Stunted g.Hematoma g.Eye Discharge g.Cough
h.Severly h.Bruises/Injuries h.Ear Discharge h. others,
Stunted Specify

i.Tall i.Itchiness i.Impacted

cerumen
j.Skin Lessions j.Mucus discharge

k.Acne/Pimple k.Nose
Bleeding(epistaxis
)
l.Capacity refill l.others, Specify
greater than 3
m. others,
specify
Note: Use Letter to record ailments and Place X if not examined
Name: _____________________________________________ LRN:____________________________________