Form No.

86
HEALTH EXAMINATION RECORD
NAME:
SCHOOL:
DATE OF BIRTH: SEX: AGE:
CIVIL STATUS: TYPE OF WORK:

1. Date: Height: cm. Weight: kg.

2. Temperature: ________________________________________________________________________________
3. Respiratory System:
Fluoroscopy: _________________________________________________________________________
Sputum Analysis: ______________________________________________________________________
4. CirculatorySystem:
Blood Pressure: _____________________ Systolic: ______________ Diastolic: ______________
Pulse: _____________________________ Sitting: _______________ Agility Test: ____________
After 3 minutes: ___________________________________
5. Digestive System: _____________________________________________________________________________
6. Genito - Urinary: _____________________________________________________________________________
7. Skin: _______________________________________________________________________________________
8. Locomotor System: ____________________________________________________________________________
9. Nervous System: ______________________________________________________________________________
10. Eyes:
Conjunctiva: __________________________________________________________________________
etc..: _________________________________________________________________________________
11. Color Perception: ____________________________________________________________________________
12. Vision: With Glasses: _______________________________ Far: _____________ Near: __________________
Without Glasses: _____________________________ Far: _____________ Near: __________________
13. Ears: ____________________________________Right Ear: _________________ Left Ear: ________________
14. Hearing: ___________________________________________________________________________________
15. Nose: ______________________________________________________________________________________
16. Throat: ____________________________________________________________________________________
17. Teeth & Gum: _______________________________________________________________________________
18. Immunization: ______________________________________________________________________________
Date of Immunization: __________________________________________________________________
19. Remarks: ___________________________________________________________________________________
_____________________________________________________________________________________
 _____________________________________________________________________________________
20. Recommendation: ____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
21. Employee's Signature: ________________________________
22. P'hysician's Signature: ________________________________