Form 86 HEALTH EXAMINATION RECORD

Name: _______________________________________________ Division: __________________________________ Department: __________________________________

Date of Birth: __________________________________________ Type of Work: _____________________________ Sex: _____________ Civil Status: __________________

Date: Date: Date:

Height: Height: Height:
Weight: Weight: Weight:
Temperature: Temperature: Temperature:
Respiratory System: Respiratory System: Respiratory System:
Fluorography: Fluorography: Fluorography:
Sputum Analysis: Sputum Analysis: Sputum Analysis:
Circulatory System: Circulatory System: Circulatory System:
Blood Pressure: Blood Pressure: Blood Pressure:
Pulse: Pulse: Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
Digestive System: Digestive System: Digestive System:
Genito-Urinary: Genito-Urinary: Genito-Urinary:
Urinalysis,etc.: Urinalysis,etc.: Urinalysis,etc.:
Skin: Skin: Skin:
Locomotor System: Locomotor System: Locomotor System:
Nervous System: Nervous System: Nervous System:
Eyes: Conjunctivitis, etc.: Eyes: Conjunctivitis, etc.: Eyes: Conjunctivitis, etc.:
Color Perception: Color Perception: Color Perception:
Vision: Vision: Vision:
With glasses: Far: _______ Near: ________ With glasses: Far: _______ Near: ________ With glasses: Far: _______ Near: ________
Without glasses: Far: _______ Near: ________ Without glasses: Far: _______ Near: ________ Without glasses: Far: _______ Near: ________
Nose: Nose: Nose:
Ear: Ear: Ear:
Hearing: Hearing: Hearing:
Right: Left: Right: Left: Right: Left:
Throat: Throat: Throat:
Teeth and Gums: Teeth and Gums: Teeth and Gums:
Immunization: Immunization: Immunization:
Remarks: Remarks: Remarks:
Recommendation: Recommendation: Recommendation:
Employee’s Signature: Employee’s Signature: Employee’s Signature:
Employee’s Name (Print): Employee’s Name (Print): Employee’s Name (Print):
Physician’s Signature: Physician’s Signature: Physician’s Signature:
Physician’s Name (print): Physician’s Name (print): Physician’s Name (print):