Appendix 11

TEACHER'S HEALTH CARD

Name: PERLA B. GALANG Date of Birth: 08/25/1968 Age: 57 Gender: M F

School/District/Division: Cielito Zamora Memorial School/District I/Caloocan Civil Status S M W S
Position/Designation: MASTER TEACHER i Years in Service:
First Year in Service: 1991

Family History: (pls. check) Y N Specify Relationship

Hypertension [ ✔ ] [ ] MOTHER
Cardiovascular Disease [ ] [ ✔ ]
Diabetes Mellitus [ ✔ ] [ ] GRANDMOTHER
Kidney Disease [ ] [ ✔ ]
Cancer [ ✔ ] [ ] MOTHER
Asthma [ ✔ ] [ ] GRANDFATHER
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) SQUID Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: 11/14/23 NORMAL Drug Testing: N/A Others specify
ECG N/A Neuropsychiatric exam: N/A
Urinalysis 3/28/2023 NORMAL Blood Typing: N/A
 Appendix 11

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
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 E [ ✔ ] [ ] Poor/loss of hearing [ ] [ ✔ ]
Easy fatigability [ ] [ ✔ ] Syncope/fainting [ ] [ ✔ ]
Joint/extremity pains e [ ✔ ] [ ] 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
 Appendix 11

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: PERLA B. GALANG Division: Caloocan Department: Cielito Zamora Memorial School
Date of Birth: 08/25/1968 Type of Work: Teacher Sex: FEMALE Civil Status: MARRIED

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: __________ 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:
Physician's Name (Print):
 Appendix 6
HNC NS Form 1
Republic of the Philippines
Department of Education
National Capital Region
Division of Caloocan
Cielito Zamora Memorial School/136635

RECORD OF DAILY TREATMENT

Chief
Date Name of Patient Grade Treatment Attended by Signature of Patient Remarks
Complaint
Name Designation