Republic of the Philippines

Department of Education
Mabalacat City
SANTOS VENTURA ELEMENTARY SCHOOL

SCHOOL HEALTH EXAMINATION CARD

Name : ___________________________________ Region III Division of Mabalacat City

Date of Birth : ______________________________ Address: _______________________________________
Name of Parent / Guardian : _______________________School Address: Osmea St. Tabun, Mabalacat City
IMMUNIZATION
RECEIVED AND
DATE GIVEN
DATE OF EXAMINATION PRE- ELEM I II III IV V VI
Weight (kg)
Height (cm)
Vision (Snellens
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 & Heart & Extremities Nutritional Remarks
Mouth Neck Lungs Status
a.Pediculosi a.Granular a.Cold/coug a.Enlarge a.Normal a.Abnormal a.Normal a.Referred
s eyelids h d b.RF/RH b.Deformitie b.Mild b.Treated
b.Tinea b.Inflamed b.Dirty Teeth tonsilitis D s c.Moderate c.Further
Flavia eyes c.Defective b.Inflamed c.CVD (Congenital d.Severe Evaluation
c.Scabies c.Squitting Teeth throat d.Asthma or Acquired) e.Overweigh d.Observatio
d.Ulcer Eyes d.Stomatitis c.Enlarge e.Primary c.Others t n
e.Minor d.pale e.Clef palate d glands Complex (specify)
Injuries conjunctiva f.Harelip d.Goiter f.Others
f.Ringworm e.Dischargin g.Defective e.Others (specify)
g.Skin g Ears Speech (specify)
Allergy f.Impacted h.Others
h.Others Cerumen (Specify)
(specify) g.Others
(specify)