KINDLY READ AND FOLLOW THE INSTRUCTIONS PER COLU

ACCOMPLISH
KINDLY DOUBLE CHECK BEFORE YOU SUBMIT YOU

DATE ACCOMPLISHED: MAY 3,2021

NAME OF SCHOOL/ OFFICE: ARCH.EMILIO CINENSE MEMORIAL INTEGRATED SCHOOL

NAME GENDER
NO AGE
(Surname, First Name, Middle Initial) (M or F)

1 BAKING, ROXANNE P. 35 F
2 AQUINO, LUCENA M. 60 F
3 BONUS, MEAGAN M. 29 F
4 BASILIO, MAJORIE B. 42 F
5 PURAON, JAMIE JANELA C. 27 F
6 BASILIO, RENMART D. 27 M
7 QUIAMBAO, JENNIFER D. 26 F
8 CANLAS, EMINA P. 53 F
9 ILLESCAS, MARICAR S. 36 F
10 MAGTOTO, SOLYDA M. 49 F
11 ESGUERRA, MA. VILMA S. 49 F
12 NARCISO, GENELYN Q. 33 F
13 SAMSON, ROSALINA L. 48 F
14 BALAGTAS, CATHERINE D. 50 F
15 SITCHON, RODELLA S. 48 F
16 DIZON, MARIA CRISTINA I. 39 F
17 MENDOZA, FLORENCE B. 46 F
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Submitted by:

School Health Leader (Elementary)

(with e-signature)

School Health Leader (Junior High School)

(with e-signature)

School Health Leader (Senior High School)

(with e-signature)

Noted
School Head
(with e-signature)

Checked and Verified:

Position - Health Personnel In-Charge

(with e-signature)
NS PER COLUMN. SOME OF THE CELLS ARE PROTECTED AND THEY
ACCOMPLISH ONE FORM PER SCHOOL ONLY.
SUBMIT YOUR SCHOOL APE FORM. THE SUBMITTED FORM IS CONS

TED SCHOOL

TEACHING INDICATE EXISTING HEALTH PROBLEM/S

COMPLIANT OR NON- DIAGNOSED BY YOUR ATTENDING
(YES or NO) TEACHING PHYSICIAN
(T or NT) (If No, put "NONE")

YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
YES T NONE
OTECTED AND THEY ARE UNABLE TO EDIT.

ITTED FORM IS CONSIDERED FINAL.

WITH
MAINTENANCE MEDICATION/S
SMOKER GRADED
PRESCRIBED BY YOUR ATTENDING
(YES or EYE
PHYSICIAN
NO) GLASSES
(If No, put "NONE")
(YES or NO)

NONE NO NO
NONE NO YES
NONE NO NO
NONE NO NO
NONE NO YES
NONE NO NO
NONE NO NO
NONE NO NO
NONE NO NO
NONE NO NO
NONE NO YES
NONE NO NO
NONE NO NO
NONE NO NO
NONE NO NO
NONE NO NO
NONE NO NO
 Republic of the Philippines
Department of Education - Region III Central Luzon
DIVISION OF CITY OF SAN FERNANDO, PAMPANGA

ANNUAL PHYSICAL EXAMINATION FORM

COMPLETE BLOOD COUNT

DATE OF LABORATORY
RESULTS
(Month/Day/Year) (Please note Abnormal Hemoglobin, WBC, Platelet
Count)
WBC- 5-10
HGB 110 - 170

4/30/2021 WBC 13.7

4/30/2021 N
4/30/2021 N
4/30/2021 N
4/30/2021 WBC 12.2
4/30/2021 N
4/30/2021 N
4/30/2021 N
4/30/2021 N
4/30/2021 N
4/30/2021 N
4/30/2021 N
4/30/2021 HEMOGLOBIN:101, HEMATOCRIT: 30
4/30/2021 N
4/30/2021 N
4/30/2021 N
4/30/2021 N
c of the Philippines
ation - Region III Central Luzon
F SAN FERNANDO, PAMPANGA

AL EXAMINATION FORM

FOR NORMAL RESULTS, PLEASE PUT "N

FASTING BLOOD
BLOOD URIC ACID TOTAL
SUGAR CREATININE
(BUA) CHOLESTEROL
(FBS)

mg/dl
5.7 and below 6 and below 200 and below
0.6-1.3
umol/L umol/L mmol/L
umol/L
105 or below/ 350 and below 5.2 and below
53-114.9

152 N N N
112 N N N
108 N N 201
N N N 264
110 N N 224
N N N N
N N N 209
138 N N N
N N N N
N N N N
128 N N N
N N N 200
N N N N
N N N N
N N N 250
N N N 209
N N N N
RMAL RESULTS, PLEASE PUT "N" (SEE BELOW FOR THE NORMAL VALUES). FOR ABNORMAL, PLEASE I
TRIGLYCERIDE
HDL LDL SGPT/ALT SGOT/AST
S

150 and below 60 and above 130 and below

U/L U/L
mmol/L mmol/L mmol/L
56 and below 40 and below
1.69 and below 1.55 and above 3.36 and below

124 N N N 45
N N N 44 57
290 N N N N
181 N 185 N N
N N N N 35
237 N N N 38
N N N 52 47
N N N N N
198 N N N N
200 N N N 38
N N N N N
N N N 45 N
156 N N N N
N N N N N
N N 186 70 49
166 N N N N
N N N N N
BNORMAL, PLEASE INDICATE THE RESULTS.

URINALYSIS Chest X-Ray

(Please note Pus Cells, RBC,

Protein/albumin and sugar)
PC For pregnant, please put "P"
MALE: 1-3
FEMALE: 2-5

ALBUMIN:+1 P
N N
ALBUMIN:+1 N
N N
N N
N N
N N
N N
N N
PUS CELL: 25-30 HPF N
SUGAR:+4,PUS CELL:5-10/HPF PTB4-Treated
N N
N N
N N
N N
RED BLOOD CELL:>50/HPF N
N N
 Sputum Microscopy ECG
(for pregnant only) 40y/o and up ONLY

For male and not pregnant female, please

put "NA"
(If below 40, please put "NA")
If no sputum microscopy, please put
"NONE"

NONE N/A
NONE N
NONE N/A
NONE N
NONE N/A
NONE N/A
NONE N/A
NONE N/A
NONE N/A
NONE N
NONE N
NONE N/A
NONE N
NONE N
NONE N
NONE N/A
NONE N
 THIS WORKSHEET IS FOR
SCHOOL HEALTH AND
NUTRITION PERSONNEL
ONLY.

DATE ACCOMPLISHED: MAY 3,2021

NAME OF SCHOOL/ OFFICE: ARCH.EMILIO CINENSE MEMORIAL INTEGRATED SCHOOL

PERSONNEL GENDER EMPLOYED COMPLIANT MISSING

MALE 1 1 0
TEACHING
FEMALE 16 16 0
MALE 0 0 0
NON-TEACHING
FEMALE 0 0 0
TOTAL 17 17 0

NO. OF COMPLIANT
NO. OF TEACHING
TOTAL NO. OF
MALE FEMALE
EMPLOYED
CONSOLIDATED
17 1 16

Checked and Verified:

0
Position - Health Personnel In-Charge
(with e-signature)
 D
DIV

ANNUAL PHY

EGRATED SCHOOL

CBC FBS CREATININE BUA

SMOKER GRADED EG
N ABF N ABF N ABF N
0 0 1 0 1 0 1 0 1
0 3 13 3 10 6 16 0 16
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 3 14 3 11 6 17 0 17

NO. OF COMPLIANT
NO. OF NON-TEACHING
TOTAL NO.
HEART
MALE FEMALE OF SMOKER GRADED EG HPN DM LUNGS DSE.
DSE.
COMPLIANT

0 0 17 0 3 0 0 0 0

TOTAL EXISTING HEALTH PROBLEM/S

HYPERTENSION
DIABETES MELLITUS
HEART DISEASE
LUNG DISEASE
OTHERS
 Republic of the Philippines
Department of Education - Region III Central Luzon
DIVISION OF CITY OF SAN FERNANDO, PAMPANGA

ANNUAL PHYSICAL EXAMINATION 2021 SUMMARY

BUA TOTAL CHOLESTEROL TRIGLYCERIDE HDL LDL

ABF N ABF N ABF N ABF N
0 1 0 0 1 1 0 1
0 9 7 9 7 0 16 14
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 10 7 9 8 1 16 15

TOTAL
OTHERS CBC FBS CREATININE BUA TRIGLY HDL
CHOLES

0 3 6 0 0 7 8 16

LIST OF MAINTENANCE MEDICATION/S

MARY

LDL SGPT/ALT SGOT/AST URINALYSIS CHEST X-RAY

ABF N ABF N ABF N ABF N
0 1 0 0 1 1 0 1
2 12 4 10 6 11 5 14
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
2 13 4 10 7 12 5 15

LDL SGPT SGOT UA CXR SM ECG

2 4 7 5 3 0 -9
CHEST X-RAY SPUTUM MICROSCOPY ECG
P (NA) ABF N NONE N/A ABF N N/A
0 0 0 0
1 3 0 16 0 0 8 0
0 0 0 0
0 0 0 0 0 0 0 0
1 3 0 16 0 0 8 0
ECG EXISTING HEALTH PROBLEMS MAINTENANCE MEDS

ABF NONE WITH NONE WITH

-1 1 0 1 0
-8 16 0 16 0
0 0 0 0 0
0 0 0 0 0
-9 17 0 17 0