Republic of the Philippines Department of Education Pasig City

SCHOOL HEALTH EXAMINATION CARD

Name : Date of Birth : Name of Parent/Guardian :

PRE-ELEM I II

Region/Division : Address : School Address:

GRADE / YEAR
III IV V VI

IMMUNIZATION RECEIVED AND DATE GIVEN

DATE OF EXAMINATION Weight (kg) Height (cm.) Vision (Snellen's Chart) Hearing Nutritional Status Skin and Scalp Eyes Ears Nose Mouth Throat Neck Heart Lungs Extremities Other Illness (identify) Remarks Examined by

Skin & Scalp a. Pediculosis b. Tinea Flava c. Scabies d. Ulcers e. Minor Injuries f. Ringworm g. Skin Allergy h. Others (specify)

Eyes & Ears a. Granular eyelids b. Inflamed eyes c. Squinting Eyes d. pale conjunctiva e. Discharging Ears f. Impacted cerumen g. Others (Specify)

Nose & Mouth a. Colds/cough b. Dirty Teeth c. Defective Teeth d. Stomatitis e. Cleft palate f. Harelip g. Defective Speech h. Others (specify)

Throat & Neck a. Enlarged tonsillitis b. Inflamed throat c. Enlarged glands d. Goiter e. Others (specify)

Heart & Lungs a. Normal b. RF / RHD c. CVD d. Asthma e. Primary complex f. Others (specify)

Extremities a. Abnormal b. Deformities (Conginital or Acquired) c. Others (specify)

Nutritional Status a. Normal b. Mild c. Moderate d. Severe e. Overweight

Remarks a. Referred b. Treated c. Further Evaluation d. OPbservation

Note: Use letter to record ailments

Republic of the Philippines Department of Education Pasig City SCHOOL DENTAL EXAMINATION CARD

D E N T I T I O N S T A T U S A N D T R E A T M E N T N TEREE A T SM E N T D
S T AT U S

RECO RD

D A T E T O O T H N NOa . t u r e o f O p e r Da E iN T I S T t on

R IG H T

55

54

53 52 51 61 62 63 64 65

LEFT

T E M P O R AR Y TE E T H

18
PERMANENT TEETH

17

16

15

14

13 12 11 21 22 23 24 25

26

27

28

48

47

46

45

44

43 42 41 31 32 33 34 35

36

37

38

STA TUS T R EA T M EN T N EED S

T E M P O R AR Y TE E T H

R IG H T
S T AT U S

85

84

83 82 81 71 72 73 74 75

LEFT

TEMPORARY TEETH I n d e x : d . f. t. P r e - S c h o o l e1rs t N o . T /d e c a y e d N o . T / fi l l e d T o ta l d . f. t.

D A T E O F V IS IT 2n d 3r d 4t h 5t h 6t h

PERMANENT TEETH
In d e x : D .M .F .T . P r e - S c h o o l e 1s t r N o . T /d e c a y e d N o . T /m is s in g N o . T / f i ll e d T o t a l D .M .F . T . T o ta l S o u n d T e e th

D A T E O F V IS IT 2n d 3r d 4t h 5t h 6t h

SYMBOLS FOR MOUTH EXAMINATION

X Carious tooth indicated for extraction F2 permanently filled tooth with recurrence of decay F Carious tooth indicated for filling Heavy Shade Permanent filling RF Root Fragment O missing tooth

Artificial Restoration

SYMBOLS FOR ACCOMPLISHMENT

P Prophylaxis CF Cement filling X Extracted permenent tooth ZnO Zinc Oxide Filling xt extracted temporary tooth Corrected correction of all ag F Amalgam filling / art defects Sy F Synthetic Porcelein Filling TF Treatment of eugenol in R Reffered to private dentist

JC Jacket Crown AB Abutment P Pontic I - Inlay Outline of Filling Tooth wioth temporary RPD Removable Partial Denture () Sound/erupted Permanent Tooth FB Fixed Bridge CD Complete Denture