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    Health Examination Record: Form 86 (Rev. 7/6/69)

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    Licca Argallon
    This document appears to be a health examination record form from the Republic of the Philippines Department of Education CARAGA Region Division of Butuan City. The form includes sections to record information about a person's name, birthdate, height, weight, temperature, and examination of their respiratory, circulatory, digestive, genitourinary, locomotor, nervous, skin, eyes, ears, nose, throat, teeth and gums, immunizations, and any remarks or recommendations. The employee and physician would sign the bottom of the form to verify the health examination.

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    Health Examination Record: Form 86 (Rev. 7/6/69)

    Uploaded by

    Licca Argallon
    110 views1 page
    This document appears to be a health examination record form from the Republic of the Philippines Department of Education CARAGA Region Division of Butuan City. The form includes sections to record information about a person's name, birthdate, height, weight, temperature, and examination of their respiratory, circulatory, digestive, genitourinary, locomotor, nervous, skin, eyes, ears, nose, throat, teeth and gums, immunizations, and any remarks or recommendations. The employee and physician would sign the bottom of the form to verify the health examination.

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    Form-86

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    This document appears to be a health examination record form from the Republic of the Philippines Department of Education CARAGA Region Division of Butuan City. The form includes sections to record information about a person's name, birthdate, height, weight, temperature, and examination of their respiratory, circulatory, digestive, genitourinary, locomotor, nervous, skin, eyes, ears, nose, throat, teeth and gums, immunizations, and any remarks or recommendations. The employee and physician would sign the bottom of the form to verify the health examination.

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    © All Rights Reserved
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    110 views1 page

    Health Examination Record: Form 86 (Rev. 7/6/69)

    Uploaded by

    Licca Argallon
    This document appears to be a health examination record form from the Republic of the Philippines Department of Education CARAGA Region Division of Butuan City. The form includes sections to record information about a person's name, birthdate, height, weight, temperature, and examination of their respiratory, circulatory, digestive, genitourinary, locomotor, nervous, skin, eyes, ears, nose, throat, teeth and gums, immunizations, and any remarks or recommendations. The employee and physician would sign the bottom of the form to verify the health examination.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
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    Form 86

    (Rev. 7/6/69)

    Republic of the Philippines


    Department of Education
    CARAGA REGION
    DIVISION OF BUTUAN CITY

    HEALTH EXAMINATION RECORD

    Name: ______________________________ Sex: _____ Civil Status: _________


    Place of Birth: ____________________________ School Assigned: ________________________
    Date of Birth: _____________________________ Type of Work: ___________________

    1. Date: _________________ Age: _______ Height: ______ Weight: _______


    2. Temp: ________________
    3. Respiratory System:
    4. X-Ray Film No. __________________________________ Date: ____________________
    Right Lung: _____________________________________
    Left Lung: ______________________________________
    Mediastinum: ___________________________________
    Impression: _____________________________________
    Recommendation: ________________________________
    5. Circulatory System :
    Blood Pressure: ___________________ Systolic: ________________ Diastolic: ________
    Pulse: __________ Sitting: _________________ Agility Test after 5 min. : _____________
    Blood Analysis: _________________________________
    6. Digestive System: _______________________________
    7. Genito/Urinalysis: ______________________________________________
    8. Loco Motor System: ____________________________________________
    9. Nervous System: _______________________________________________
    10. Skin: ________________________________________________________
    11. Eyes, Conjunction: _____________________________________________
    12. Color Perception: ______________________________________________
    13. Vision,w/, w/o glasses: _________________________________________
    14. Ears: ________________________________________________________
    15. Hearing: _____________________________________________________
    16. Nose: _______________________________________________________
    17. Throat: ______________________________________________________
    18. Teeth and Gums: ______________________________________________
    19. Immunization : ________________________________________________
    20. Remarks: ____________________________________________________
    21. Recommendation: ________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    22. Employee’s Signature: ______________________________
    23. Physician’s Signature: ______________________________

    Checked by:

    ____________________________________
    District Nurse

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