SHD Form 4

TEACHER'S HEALTH CARD

Date:
Name: Christopher C. Castillo Date of Birth: 26-Oct-85 Age: 38 Gender: Male
School/District/Division: Liliw National High School Liliw District /Laguna Civil Status Married
Position/Designation: Head Teacher I Years in Service: 13
First Year in Service: 2010

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) [ ] [/ ]
Covid-19 [ ] [/ ]
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
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
Menopause: ________________
Parity: F P A L
Papsmear done: 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:
CS Form 86

SHD Form 4-A

HEALTH EXAMINATION RECORD
Name: CHRISTOPHER C. CASTILLO Division: Laguna Department: Deped
Date of Birth: 26-Oct-85 Type of Work: Teaching Sex: Male Civil Status: Married

1 Date: Date: Date:

Height (m) Height (m) Height (m)
Weight (kg) Weight (kg) Weight (kg)
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: __________ Near: _________
Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee's Signature:
Employee's Name (Print):
21 Physician's Signature:
CS Form 86

Physician's Name (Print):