Document Code: TarPr-QF-SGOD-SHU-10

Quality Form Revision: 01

Effectivity date: 10-16-2018

Teachers Health Card Name of Office:

SGOD-SHU

Date:_____________
Name:_______________________________ Date of Birth:__________ Age:_____ Gender: M F
School/District/Division:__________________ Civil Status: S M W S
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 [ ] [ ]
Cardio Vascular Disease [ ] [ ] Last Hospitalization (reason) [ ] [ ]
Allergy (pls. specify) [ ] [ ] Others (pls. specify)___________________
Last Taken Date Result Date Result
CXR/Sputum Result: ______ ______ Drug Testing: ______ ______ Others: specify _______
ECG ______ ______ Neuropsychiatric exam ______ ______
Urinalisys ______ ______ Blood Typing: ______ ______
Social History
Smoking Y_____ N_____ Age Started: _______ Sticks/packs per day: _____ Pack per year: ____
Alcohol Y_____ N_____ How often: ________ Food Preference: ________

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

Menarche __________ Cycle __________ Duration __________
Parity: F P A L
Papsmear done: Y N if YES, when: ___________
Self Breast Exam 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 1month Longer [ ] [ ] Lumps [ ] [ ]
Dizziness [ ] [ ] Painful urination [ ] [ ]
Dyspnea [ ] [ ] Poor/loss of hearing [ ] [ ]
Chest/Back pain [ ] [ ] Syncope/fainting [ ] [ ]
Easy fatigability [ ] [ ] Convulsions [ ] [ ]
Joint/extremity pains [ ] [ ] Malaria [ ] [ ]
Blurring of Vision [ ] [ ] Goiter [ ] [ ]
Wearing eyeglasses [ ] [ ] Anemia [ ] [ ]
Vaginal discharge/bleeding [ ] [ ] others: (pls. specify) [ ] [ ]
Dental Status: (pls. specify)____________________________
Present medication taken: (pls. specify) ______________________________________________________
Legend: CXR -Chest X-ray PTB -Pulmonary Tuberculosis
ECG -Electro Cardio Gram F -Full Term

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 Document Code: TarPr-QF-SGOD-SHU-10

Quality Form Revision: 01

Effectivity date: 10-16-2018

Teachers Health Card Name of Office:

SGOD-SHU

Y -Yes P -Pre mature

N -No A -Abortion
HPN -Hypertension L -Live Birth
CVD -Cardio Vascular Disease
DM -Diabetes Mellitus
Interviewed by: _____________________________
Date: ________________
CONSULTATION AND TREATMENT RECORD:

Date / Signature of Chief Complaint Findings Treatment /

Attending Physician Recommendation

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