CS Form 86

Department of Education
Caraga Administrative Region
Division of Agusan del Sur
Prosperidad District VI
LOS ARCOS NATIONAL HIGH SCHOOL
School ID : 304720
HEALTH EXAMINATION RECORD

Name: JEFFREY A. TRAZO Division: AGUSAN DEL SUR School/District: LOS ARCOS NHS/ PROSPERIDAD VI
Date of Birth: NOVEMBER 8, 1988 Type of Work: TEACHING Sex: MALE Civil Status: MARRIED

1 Date:
Height
Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:

5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: _________Near: _________
Without glasses: Far: _________Near: _________
12 Nose:
13 Ear:
14 Hearing:
Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:

18 Remarks

19 Recommendation

Employee's Signature:
20
Employee's Name (Print):

Physician's Signature:
21
Physician's Name (Print):
CS Form 86

Ten
 CS Form 86

ment of Education
dministrative Region
of Agusan del Sur
ridad District VI
TIONAL HIGH SCHOOL
ol ID : 304720

MARRIED