Department of Education

Region III
City School Division of Mabalacat
MABALACAT NORTH DISTRICT
Mabalacat City (P)

General Form No. 86

HEALTH EXAMINATION FORM

Name: ____________________________________________________ Bureau of Public School, Department of Education

Date of Birth: Date:

1. Date: Age: Height:

2.Temperature Weight:
3. Respiratory System
Sputum Analysis
4. Circulatory Sys.
5. Blood Pressure Systolic: Diastolic:
Pulse: Sitting: Agility test:
Blood Analysis
Digestive System
6.Genite
Urinalysis, etc.
7. Skin
8. Loco-Motor System
9. Nervous System
10. Eye-Conj. Etc.
11. Calorie Perception
12. Vision without
Glasses (Right) Far: Near: (Left)Far: Near:
w/ Glasses (Right) Far: Near: (Left)Far: Near:
13. Ears
14. Hearing Right Ear: Left Ear:
15. Nose
16. Throat
17. Teeth and Gum
18. Immunization
Date
19. Remarks

20. Recommendation

21. Emloyee's Signature _________________________________________________________________

22. Physicians Signature: _________________________________________________________________