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SHD FORM 1
SHD FORM 1-A

Republic of the Philippines
DEPARTMENT OF EDUCATION
Region 02-Cagayan Valley Name: __________________________________ LRN: ______________________________
Division of Nueva Vizcaya
LAMO NATIONAL HIGH SCHOOL Medical History (For Learners)
Lamo, Dupax del Norte, Nueva Vizcaya
1. Do you have any allergies? _____ Yes _____ No
If Yes, please identify below:
SCHOOL HEALTH EXAMINATION CARD _____ Medicine (Gamot) ________________
_____ Pollens
Name: _________________ _____________________ _______________ _______ _____ Food (Pagkain) ___________________
Last First Middle Suffix _____ Stingin Insects (Kagat ng Insekto)
_____ Others: ___________________________________________________________
Date of Birth: _________________________ Birthplace: _________________________
Month/Day/Year
2. Do you have any ongoing medical condition? _____ Yes _____ No
Parent/Guardian: ___________________________ Cellphone No: _______________________ If Yes, please identify below:
_____ Error of refraction (Malabong mata)
Home Address: _________________________________________________________________ _____ Asthma (hika)
_____ Seizure
_____ Heart Problem (Sakit sa Puso)
_____ Anemia
_____ Bleeding Disorder
Data Privacy Notice _____ Others: ___________________________________________________________
The Department of Education Shall engage in the collection of health/medical 3. Have you ever had surgery/hospitalization? _____ Yes _____ No
information for the purposes of tracking, provision of necessary health/medical interventions, and If Yes, please identify below:
educational purposes. This information shall be processed in accordance with the provisions of _______________________________________________________________________
the Data Privacy Act and the Data Privacy Policies of the Department.
4. Does anyone in your family have the following conditions:
This information shall be stored and held confidentially in accordance with the _____ Tuberculosis
provisions of the Basic Education Act and may only be shared with other government agencies or _____ Cancer If Yes, What Kind? _________________________________
third parties subject to Data sharing agreements and data privacy requirements for legitimate _____ Stroke
purposes only. _____ Diabetes Mellitus
_____ Hypertension
For inquiries, requests and concerns regarding your data privacy rights, please contact _____ Depression
the data privacy compliance officer, team of the school, schools division office or regional office _____ Others: ___________________________________________________________
concerned.
5. Exposure to cigarette/vape smoke at home? _____ Yes _____ No
I hereby authorize the Department of Education to use, collect and process the
information for the purposes of the above stated. 6. Which hand is used for writing? _____ Right _____ Left _____ Both
I certify that the above information is correct.

_____________________________ _____________________________
Name and Signature of Child Name and Signature of Parent/Guardian
_____________________________
Name and Signature of Parent/Guardian
SHD FORM 1-B
Name: _____________________________________________________________ LRN: ______________________________
MEDICAL/NURSING FINDINGS
GRADE 7 GRADE 8 GRADE 9 GRADE 10 GRADE 11 GRADE 12

Findings Findings Findings Findings Findings Findings
Date of Examination
Height (cm)
Weight (kg)
Nutritional Status (BMI/
Weight for age)
Nutritional Status (Height for
age)
4Ps Beneficiary
Deworming Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan
Iron Supplementation
Immunization (Specify what
kind)
Menarche (for girls)

Temperature/BP
HR/PR/HR
Vision Screening
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/throat Heart/Lung Abdomen Deformities
Screening
a. Normal Weight Vision a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
(Spcify)
b. Severely Wasted Passe L R b. Presence of Lice b. Inflamed Eye lid b. Enlarged tonsils b. Rales b. Distended
d
c. Wasted Failed L R c. Redness of skin c. eye redness c. presence of c. wheeze c. Abdominal Pain b. Congenital
lesions (specify)
d. Overweight Auditory d. White spots d. Ocular d. Inflamed pharynx d. Murmur d. Tenderness
Misalignment
e. Obese Passe L R e. Flaky Skin e. Pale Conjunctiva e. Enlarged Lymph e. Irregular heart e. Dysmenorrhea
d nodes rate
f. Normal Height Failed L R f. Impetigo f. Matted Eyelashes f. Others f. Colds f. Others
g. Stunted g. Hematoma g. Eye Discharge g. Cough
h. Severely Stunted h. Bruises h. Ear Discharge
i. Tall i. Itchiness i. Impacted
Serumen
j. Skin Lesions j. Mucus Discharges
k. Acne/Pimple k. Nose bleeding
l. Capillary Refill l. Others
greater than 3
m. Others
SHD FORM 1-D
Name: ____________________________________________________________ LRN: ______________________________
DENTAL FINDINGS
Grade 7 S.Y. ___________________ Grade 8 S.Y. _________________ Grade 9 S.Y. ________________
Grade 10 S.Y. ___________________ Grade 11 S.Y. _________________ Grade 12 S.Y. ________________
ORAL HEALTH CONDITION

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SHD FORM 1

SHD FORM 1-A

I certify that the above information is correct.

Name: _______________________________ LRN:

GRADE 7 GRADE 8 GRADE 9 GRADE 10 GRADE 11 GRADE 12

Menarche (for girls)

Examined by: ___________________ Designation:

Name: ______________________________ LRN:

Grade 7 S.Y. ___________ Grade 8 S.Y. _ Grade 9 S.Y. ________

Grade 10 S.Y. ___________ Grade 11 S.Y. _ Grade 12 S.Y. ________

ORAL HEALTH CONDITION

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