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Republic of the Philippines

Department of Education
Davao City
SCHOOL HEALTH EXAMINATION CARD
Name : Region/Division :
Date of Birth : Address :
Name of Parent/Guardian : School Address:
GRADE / YEAR IMMUNIZATION RECEIVED AND
PRE-ELEM I II III IV V VI
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 Eyes & Ears Nose & Throat & Neck Heart & Lungs Extremities Nutritional Remarks
Mouth Status
a. Pediculosis a. Granular a. a. Enlarged a. Normal a. Abnormal a. Normal a. Referred
b. Tinea Flava eyelids Colds/cough tonsillitis b. RF / RHD b. Deformities b. Mild b. Treated
c. Scabies b. Inflamed eyes b. Dirty b. Inflamed c. CVD (Conginital or c. Moderate c. Further
d. Ulcers c. Squinting Eyes Teeth throat d. Asthma Acquired) d. Severe Evaluation
e. Minor d. pale c. Defective c. Enlarged e. Primary c. Others e. Overweight d.
Injuries conjunctiva Teeth glands complex (specify) OPbservation
f. Ringworm e. Discharging d. Stomatitis d. Goiter f. Others
g. Skin Allergy Ears e. Cleft e. Others (specify)
h. Others f. Impacted palate (specify)
(specify) cerumen f. Harelip
g. Others g. Defective
(Specify) Speech
h. Others
(specify)
Note: Use letter to record ailments
Republic of the Philippines
Department of Education
Pasig City

SCHOOL DENTAL EXAMINATION CARD

TEMPORARY TEETH PERMANENT TEETH

SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration SYMBOLS FOR ACCOMPLISHMENT


X Carious tooth indicated for extraction F2 permanently filled tooth JC Jacket Crown P Prophylaxis CF Cement filling
with recurrence of decay AB Abutment X Extracted permenent tooth ZnO Zinc Oxide Filling
F Carious tooth indicated for filling Heavy Shade Permanent filling P Pontic xt extracted temporary tooth Corrected correction of all
I - Inlay ag F Amalgam filling / art defects
RF Root Fragment Outline of Filling Tooth wioth temporary RPD Removable Partial Denture Sy F Synthetic Porcelein Filling TF Treatment of eugenol in
O missing tooth () Sound/erupted Permanent Tooth FB Fixed Bridge R Reffered to private dentist
CD Complete Denture