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    Teachers Health Examination Form

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    Noly Mariano Alejandro
    This document is a teacher's health card that collects medical information such as family history of illnesses, past medical history, social history including smoking and drinking, and current health status. It includes checkboxes and spaces to record things like blood pressure readings, ECG and other test results, pregnancies and births for female teachers. The health card is used to document a teacher's full medical background and current health condition.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Teachers Health Examination Form

    Uploaded by

    Noly Mariano Alejandro
    1K views2 pages
    This document is a teacher's health card that collects medical information such as family history of illnesses, past medical history, social history including smoking and drinking, and current health status. It includes checkboxes and spaces to record things like blood pressure readings, ECG and other test results, pregnancies and births for female teachers. The health card is used to document a teacher's full medical background and current health condition.

    Original Description:

    just remove the header for your own school

    Original Title

    Teachers Health Examination Form (1)

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    This document is a teacher's health card that collects medical information such as family history of illnesses, past medical history, social history including smoking and drinking, and current health status. It includes checkboxes and spaces to record things like blood pressure readings, ECG and other test results, pregnancies and births for female teachers. The health card is used to document a teacher's full medical background and current health condition.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    1K views2 pages

    Teachers Health Examination Form

    Uploaded by

    Noly Mariano Alejandro
    This document is a teacher's health card that collects medical information such as family history of illnesses, past medical history, social history including smoking and drinking, and current health status. It includes checkboxes and spaces to record things like blood pressure readings, ECG and other test results, pregnancies and births for female teachers. The health card is used to document a teacher's full medical background and current health condition.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
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    SHD Form 4

    TEACHER'S HEALTH CARD


    Date:
    Name: Date of Birth: Age: Gender:
    School/District/Division: Civil Status
    Position/Designation: Years in Service:
    First Year in Service:

    Family History: (pls. check) Y N Specify Relationship


    Hypertension [ ] [ ]
    Cardiovascular Disease [ ] [ ]
    Diabetes Mellitus [ ] [ ]
    Kidney Disease [ ] [ ]
    Cancer [ ] [ ]
    Asthma [ ] [ ]
    Allergy [ ] [ ]
    Other Remarks:

    Past Medical History: (check)


    Y N Y N
    Hypertension [ ] [ ] Tuberculosis [ ] [ ]
    Asthma [ ] [ ] Surgical Operations (pls. specify) [ ] [ ]
    Diabetes Mellitus [ ] [ ] Yellowish discoloration of skin/sclera [ ] [ ]
    Cardiovascular Disease [ ] [ ] Last hospitalization (reason) [ ] [ ]
    Allergy (pls. specify) Other (pls. specify)
    Last Taken Date Result Date Result
    CXR/Sputum Result: Drug Testing: Others specify
    ECG Neuropsychiatric exam:
    Urinalysis Blood Typing:

    Social History
    Smoking Y N Age started: Sticks/packs per day: s per year:
    Alcohol Y N How often: Food preference:

    OB Gyn History (pls. encircle) (Female Teachers)


    Menarche: Cycle Duration
    Menopause:
    Parity: F P A L
    Papsmear don: Y N if YES, When:
    Self Breast examination done: Y N
    Mass noted: Y N Specify where
    For Male personnel: Digital rectal examination done: Y N Date examined:
    Result:
    Present Health Status (pls. check) Y N Y N
    Cough 2wks 1 month longer
    Dizziness [ ][ ] Lumps [ ] [ ]
    Dyspnea [ ][ ] Painful urination [ ] [ ]
    Chest/Back pain [ ][ ] Poor/loss of hearing [ ] [ ]
    Easy fatigability [ ][ ] Syncope/fainting [ ] [ ]
    Joint/extremity pains [ ][ ] Convulsions [ ] [ ]
    Blurring of vission [ ][ ] Malaria [ ] [ ]
    Wearing eyeglasses [ ][ ] Goiter [ ] [ ]
    Vaginal discharge/bleeding [ ][ ] Anemia [ ] [ ]
    Dental Status: (pls. specify) Others: Pls. specify)
    Present Medication taken: (pls. specify)
    Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis
    EXG - Electro Cardio Gram F - Full Term
    Y - Yes P - Pre-mature
    N - No A - Abortion
    SHD Form 4

    HP - Hypertension L - Live Birth


    CVD - Cardio Vascular Disease
    DM - Diabetes Mellitus Interviewed by:
    Date:

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