SHD Form 4 - Teacher's Health Card.xlsx

	A	B	C	E	F	G	H	J	K	L	M	N	O	P	Q	S	T	U	V	W
1	SHD Form 4
2	TEACHER'S HEALTH CARD
3
4	Date:
5	Name:							Date of Birth:							Age:		Gender:
6	School/District/Division:																Civil Status
7	Position/Designation:																Years in Service:
8	First Year in Service:
9
10		Family History: (pls. check)						Y	N				Specify Relationship
11			Hypertension					[ ]	[ ]
12			Cardiovascular Disease					[ ]	[ ]
13			Diabetes Mellitus					[ ]	[ ]
14			Kidney Disease					[ ]	[ ]
15			Cancer					[ ]	[ ]
16			Asthma					[ ]	[ ]
17			Allergy					[ ]	[ ]
18		Other Remarks:
19
20
21		Past Medical History: (check)
22									Y	N									Y	N
23			Hypertension						[ ]	[ ]		Tuberculosis							[ ]	[ ]
24			Asthma						[ ]	[ ]		Surgical Operations (pls. specify)							[ ]	[ ]
25			Diabetes Mellitus						[ ]	[ ]		Yellowish discoloration of skin/sclera							[ ]	[ ]
26			Cardiovascular Disease						[ ]	[ ]		Last hospitalization (reason)							[ ]	[ ]
27			Allergy (pls. specify)									Other (pls. specify)
28		Last Taken				Date		Result							Date	Result
29			CXR/Sputum Result:								Drug Testing:							Others specify
30			ECG								Neuropsychiatric exam:
31			Urinalysis								Blood Typing:
32
33		Social History
34			Smoking	Y		N		Age started:				Sticks/packs per day:						Packs per year:
35			Alcohol	Y		N		How often:				Food preference:
36
37		OB Gyn History (pls. encircle) (Female Teachers)
38			Menarche:				Cycle					Duration
39			Menopause: ________________
40			Parity:					F	P	A		L
41			Papsmear done:					Y	N			if YES, When:
42			Self Breast examination done:					Y	N
43			Mass noted:					Y	N			Specify where
44			For Male personnel: Digital rectal examination done:										Y	N		Date examined:
45																Result:
46
47		Present Health Status (pls. check)								Y	N								Y	N
48			Cough	2wks		1 month		longer
49			Dizziness							[ ]	[ ]		Lumps						[ ]	[ ]
50			Dyspnea							[ ]	[ ]		Painful urination						[ ]	[ ]
51			Chest/Back pain							[ ]	[ ]		Poor/loss of hearing						[ ]	[ ]
52			Easy fatigability							[ ]	[ ]		Syncope/fainting						[ ]	[ ]
53			Joint/extremity pains							[ ]	[ ]		Convulsions						[ ]	[ ]
54			Blurring of vission							[ ]	[ ]		Malaria						[ ]	[ ]
55			Wearing eyeglasses							[ ]	[ ]		Goiter						[ ]	[ ]
56			Vaginal discharge/bleeding							[ ]	[ ]		Anemia						[ ]	[ ]
57			Dental Status: (pls. specify)										Others: Pls. specify)
58			Present Medication taken: (pls. specify)
59
60			Legend:	CXR	-		Chest X-ray						PTB	-	Pulmonary Tuberculosis
61				EXG	-		Electro Cardio Gram						F	-	Full Term
62				Y	-		Yes						P	-	Pre-mature
63				N	-		No						A	-	Abortion
64				HPN	-		Hypertension						L	-	Live Birth
65				CVD	-		Cardio Vascular Disease
66				DM	-		Diabetes Mellitus						Interviewed by:
67													Date:
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