Department of Education

DIVISION OF Pagadian City

HEALTH AND NUTRITION SECTION

EXAMINATION CARD

Name: _____________________________________________________________________ School ID: _____________________________

Last First Middle

LRN: _____________________________________

Date of Birth: _______________________________ Birthplace: __________________ Region: _____________________________

Parent/Guardian: ____________________________________________________________ Division: _____________________________

Address: ___________________________________________________________________ Tel. No.: _____________________________

Kinder Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
FINDINGS
Date of Examination
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Height
Weight
Nutritional Status (Weight-for-Age)
Nutritional Status (Height-for-Age)
Vision Screening
Skin/Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen
Deformities
Iron Supplementation ( or )
Deworming ( or )
Immunization (specify)
SBFP Beneficiary ( or )
4Ps Beneficiary ( or )
Menarche ( the Start)
Others, specify
Examined by:

Legend:
Vision/Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Lungs/Heart Abdomen Deformities
Screening
a. Normal a. Pass a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
b. Wasted b. Failed b.Lice b. Sty b. Enlarged Tonsils b. Rales b. Distended b. Congenital
(Specify)
c. Severely c. Redness of Skin c. Redness c. Presence of c. Wheeze c. Abdominal
Wasted Lesions Pain
d. Overweight d.White Spots d. Ocular d. Inflamed Pharynx d. Murmur d. Tenderness
Misalignment
e. Obese e. Flaky Skin e. Pale e. Enlarged Lymph e. Irregular e. Dysmenorrhea
Conjunctiva Nodes Heart Rate
f. Normal f. Impetigo/Boil f. Ear Discharge f. Others, Specify f. Others, f. Others,
Specify Specify
g. Stunted g. Hematoma g. Impacted
Cerumen
h. Severely h.Bruises/Injuries h. Mucus
Stunted Discharge
i. Tall i. Itchiness i. Epistaxis
j. Skin Lesions j. Eye Discharge
k. Acne/Pimple k. Matted
Eyelashes
Note: Use letter to record ailments and place  if not examined.