Republic of the Philippines Department of Education Region IV A

Form 86

Republic of the Philippines

Department of Education
Region IV-A CALABARZON
Division of Quezon
GUMACA EAST DISTRICT
Gumaca

HEALTH EXAMINATION FORM

Name:
Address:
Age:

REOJUNE A. BEQUILLO
841 BRGY. ROSARIO, GUMACA, QUEZON
33
Sex:
MALE

1. Weight (kg):
2. Respiratory System:

Height (cm):

Office/Work:
Type of Work:
Civil Status:

DEPED-GUMACA EAST DISTRICT

TEACHER I
MARRIED

9. Eyes:
10. Color Perception:

Chest X-Ray:
11. Vision:
With Glasses:
Without Glasses:

3.Circulatory System:
12.Ears:
Blood Pressure:
Systolic:
Diastolic:
Pulse:
4.Digestive System:

13.Hearing:
14.Nose:
15.Throat:

5. Genito-Urinary:
16. Teeth & Gums:
6. Skin:
17. Immunization:
7. Locomotive System:
18. Remarks:
8.Nervous System:

19.Reccomendation:

Signature of Teacher/Employee
Date:
Place:

Medical Officer

DepED BESRA TED-TWG