2019 SHD Form 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region X
Division of Gingoog City

LUNAO CENTRAL SCHOOL /128069

School Name/ID

SCHOOL HEALTH EXAMINATION CARD

Name:
___________________________________________________________________________
Last First Middle
Date of Birth: ______________________ Birthplace: ______________________________
Month/Day/Year
School ID: ________________________ Region: _____________________
Learner Reference Number (LRN): __________________ Division: ____________________

Parent/Guardian: ________________________________ Telephone No.: ______________

Home Address:
__________________________________________________________________
___________________________________________________________________________

Data Privacy Notice

The Department of Education shall engage in the collection of health/medical

information for the purposes of tracking, provision of necessary health/ medical
interventions, and educational purposes. The information shall be processed in accordance
with the provisions of the Data Privacy Act
and the Data Privacy Policies of the Department.
The information shall be stored and held confidentially in accordance with the
provisions of the Basic Education Act and may only be shared with other government
agencies or third parties subject to Data sharing agreements and data privacy requirements
for legitimate purposes only.

I hereby authorize the Department of Education to use, collect and process the
information for the above stated.

__________________________________ _________________________________
Name and Signature of Child Name and Signature of Parent
2019 SHD Form 1-A

Name: _______________________________________ LRN: ____________________________

Medical History (For Learners)

1. Do you have any allergies? __________ Yes __________ No

If yes please identify below:

______ Medicine
______ Pollens
______ Food
______ Stinging Insects
______ Others: _______________________________________________________________

2. Do you have any ongoing medical condition?

If yes, please identify below:
______ Error of refraction
______ Asthma
______ Seizure
______ Heart Problem
______ Anemia
______ Bleeding Disorder
______ Hernia (painful bulge in the groin area)
______Others: _________________________________________________________________

3. Have you ever had a surgery/hospitalization? _______ Yes _______ No

If yes, please identify below:
___________________________________________________________________________

4. Does anyone in your family have the following conditions:

________Tuberculosis If Yes, What kind? ____________________

________Cancer
________ Stroke
________ Diabetes Mellitus
________ Hypertension
________ Depression
________ Others: ________________________________________________________

5. Exposure to cigarette/vape smoke at home? _______ Yes _______ No

6. Which hand is used for writing?

________ Right ________ Left _______ Both

I certify that the above information’s are correct.

_______________________________________ _______________________
Name & Signature of Parent/Guardian Date