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  • SHN Form 001 School Health Examination Card Elementary

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    John Bunay
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    This document is a school health examination card used by the Department of Education Region III Schools Division Office of Tarlac Health and Nutrition Unit. The two-page card collects personal information of a student such as name, date of birth, address and collects health information through various grades such as temperature, height, weight, nutrition status, vision and hearing screenings, and examinations of the skin, eyes, ears, nose, mouth, throat, lungs, heart, abdomen and any deformities. The card also tracks immunizations, supplements, and programs the student participates in. Examiners will fill out the card and use it to monitor students' health over multiple grades.

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    SHN-Form-001-School-Health-Examination-Card-Elementary

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    This document is a school health examination card used by the Department of Education Region III Schools Division Office of Tarlac Health and Nutrition Unit. The two-page card collects personal information of a student such as name, date of birth, address and collects health information through various grades such as temperature, height, weight, nutrition status, vision and hearing screenings, and examinations of the skin, eyes, ears, nose, mouth, throat, lungs, heart, abdomen and any deformities. The card also tracks immunizations, supplements, and programs the student participates in. Examiners will fill out the card and use it to monitor students' health over multiple grades.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    22 views2 pages

    SHN Form 001 School Health Examination Card Elementary

    Uploaded by

    John Bunay
    This document is a school health examination card used by the Department of Education Region III Schools Division Office of Tarlac Health and Nutrition Unit. The two-page card collects personal information of a student such as name, date of birth, address and collects health information through various grades such as temperature, height, weight, nutrition status, vision and hearing screenings, and examinations of the skin, eyes, ears, nose, mouth, throat, lungs, heart, abdomen and any deformities. The card also tracks immunizations, supplements, and programs the student participates in. Examiners will fill out the card and use it to monitor students' health over multiple grades.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    of 2

    Republic of the Philippines Document Code: SDO-QF-SGOD-HAN-001

    Department of Education
    Revision: 00
    Region III
    Schools Division Office of Tarlac Effectivity date: 05-25-2018
    Health and Nutrition Unit

    School Health Examination Card


    Name of Office:
    Health and Nutrition Unit

    NAME ________________________________________________________ School ID:________________________________


    Last First Middle
    Date of Birth____________________________________________________ Region:________________________________
    Month Day Year
    Birthplace______________________________________________________
    Parent/Guardian_________________________________________________ Division _________________________________
    Address________________________________________________________ Telephone No.___________________________

    Kinder/ Grade 1/ Grade 2/ Grade 3/ Grade 4/ Grade 5/ Grade 6/ Grade 7/ Grade 8/ Grade 9/ Grade Grade Grade
    SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED 10/ 11/ 12/
    SPED SPED SPED

    Date of Examination
    Temperature/BP
    Heart Rate/Pulse Rate/Respiratory Rate
    Height (in cm)
    Weight (in kg)
    Nutritional Status (NS)(BMI/Wt-for-Age)
    Nutritional Status (NS) ( Height-for-Age)
    Vision screening using appropriate chart
    Auditory screening (Tuning Fork)
    Skin/Scalp
    Eyes/Ears/Nose
    Mouth/Throat/Neck
    Lung/Heart
    Abdomen
    Deformities
    Iron supplementation( v or X)
    Deworming (v or X)
    Immunization (specify what kind)
    SBFP Beneficiary (v or X)
    4p’s Beneficary (v or X)
    Menarche (v the start)
    Others, specify
    Examined by:

    QM - Page 1 of 2
    Republic of the Philippines Document Code: SDO-QF-SGOD-HAN-001
    Department of Education
    Revision: 00
    Region III
    Schools Division Office of Tarlac Effectivity date: 05-25-2018
    Health and Nutrition Unit

    School Health Examination Card


    Name of Office:
    Health and Nutrition Unit

    LEGEND:
    NS Vision/ Auditory Skin/ Scalp Eye / Ear / Nose Mouth / Neck /Throat Lungs / Heart Abdomen Deformities
    screening
    a. Normal a. Passed a. Normal a. Normal a. Normal a. Normal lungs a. Normal a. Acquired
    weight
    b. wasted/ b. Failed b. presence of lice b. stye b. enlarged tonsils b. Normal heart b. Distended b. Congenital
    underweight ( specify)
    c. severely c. redness of skin c. eye redness c. presence of lesions c. Rales c. Abdominal
    wasted/ Pain
    underweight
    D .white spots d. ocular misalignment d. inflamed pharynx d. Wheeze d. Tenderness
    d. overweight
    e. flaky skin e. pale conjunctiva e. enlarged lymph nodes e. Murmur e.
    e.Obese dysmenorrhea
    f.Normal f. impetigo/ boils f. ear discharge f. Enlarged thyroid gland f. Irregular heart rate f. Others, specify
    Height
    g. hematoma g. impacted cerumen g. dental problem g. others, specify
    g.Stunded
    h. severely h. bruises/ injuries h. mucus discharge h. others, specify
    Stunded

    i. itchiness i. nose bleeding


    i. Tall (epistaxis)
    j. skin lesions j. eye discharge

    k. acne/Pimple k. Matted eyelashes

    QM - Page 2 of 2

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