DEPED CITY OF NAGA DIVISION

CS FORM 86 HEALTH EXAMINATION RECORD

Name: Division of: City of Naga Official Station: __
Date of Birth: Type of Work: ( ) Teaching ( ) Non Teaching Sex: Civil Status: _____
1. Date Examined: ___________
Height: ___________
Weight in Kgs.:___________
2. Temperature: ____________
3. RESPIRATORY SYSTEM:
Fluoroscopy / X- ray Results:
Sputum Results:
4. CIRCULATORY SYSTEM:
Blood Pressure:
Pulse Rate: Sitting: Agility Test:
Respiratory Rate:
5. DIGESTIVE SYSTEM:
Clinical Findings:
6. GENITO – URINARY:
Urinalysis Results, etc:
7. SKIN: (Clinical Findings):
8. LOCOMOTOR: (Clinical Findings):
9. NERVOUS SYSTEM: (Clinical Findings):
10. EYES: Color Perception: With Conjunctivitis:
Eye defects:
11. EYES: VISION: With Glasses: Farsighted: Nearsighted:
Without Glasses: Clinical Findings:
12. NOSE: Clinical Findings:
13. EARS: Clinical Findings:
14. HEARING CONDITION: Right: ______________________
Left: _______________________
15. THROAT: Clinical Findings:
16. TEETH AND GUMS: Dental Findings: (See the School Dentist / Dentist): ______
Dentist Name: Signature:
17. REPRODUCTIVE SYSTEM: Clinical Findings: Breast / etc.:
18. Any Immunization:
19. CLINICAL IMPRESSIONS/FINDINGS:
20. RECOMMENDATIONS:

Informe: Seen / Examined by a government Physician / Physician

Employee’s Name / Signature Physician’s Name / Signature

PTR/ License No.

Note:
1. The attending Physician / Dentist is encourage to fill-up from items no. 1-20 required for the information
of the office (while the actual examination and interview to the client is conducted).
2. The personnel concerned must attach his / her original laboratory result in this form as reference by the
physician.