SHD Form 1-B

Name : ________________________________________ LRN : _______________________________________

Medical/Nursing Findings
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/
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings
Date of Examination

Height (in cm)

Weight (in kg)

Nutritional Status (NS) (BMI/Wt-for-Age)

Nutritional Status (NS) (Height-for-Age)

4Ps Beneficiary (√ or X)

SBFP Beneficiary (√ or X)
Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan
Deworming (√ or X)

Iron Supplementation (√ or X)

Immunization (Specify what kind)

Menarche

Temperature/BP

Heart Rate/Pulse Rate/Respiratory Rate

Vision Screening using appropriate chart

Auditory Screening (Tuning Fork)

Skin/ Scalp

Eyes/Ears/Nose

Mouth/Throat/Neck

Lungs/Heart

Abdomen

Deformities

Others, specify

Examined by: _________________________________ Designation: _________________________________

LEGEND:

Vision/ Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities
Screening
a. Normal Weight a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
Vision (Specify)
b. Wasted a. L R b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended
Passed
c. Severely b. Failed L R c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain b. Congenital
Wasted/Underwt (Specify)
d. Overweight d. White Spots d. Ocular Misalignment d. Inflamed pharynx d. Murmur d. Tenderness
Auditory

e. Obese a. L R e. Flaky Skin e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart rate e. Dysmenorrhea
Passed
f. Normal Height b. Failed L R f. Impetigo/boil f. Others , specify f. Others, Specify
f. Matted Eyelashes f. colds

g. Stunted g. Hematoma g. Eye Discharge g. Cough

h. Severely Stunted h. Bruises/ Injuries h. Ear dischrage h. Others, specify

i. Tall i. Itchiness i. Impacted cerumen

j. Skin Lessions j. Mucus discharge

k. Acne/Pimple k. Nose Bleeding

(Epistaxis)
l. Capillary refill l. Others, specify
greater than 3
seconds
 m. others, specify

Note: Use Letter to record ailments and Place X if not examined