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Form No. 86: Division of Bukidnon
Form No. 86: Division of Bukidnon
Department of Education
Region X
DIVISION OF BUKIDNON
Sumpong, Malaybalay City
Form No. 86
PHYSICAL AND MEDICAL HEALTH RECORD
Name: Position:
School: District:
Age: Sex: Civil Status: Contact No:
Birthplace: Race/Ethnicity:
Permanent Address:
DATE EXAMINED:
1. Vital Signs:
Temperature: °C
Chest X-Ray / Sputum Exam
BMI: ( )
Result:
Height: cm Weight: kg
PR: bpm RR: cpm Date Taken:
2. Eyes/Conjunctiva:
Color Perception:
9. Circulatory System:
Vision:
VA of: Left Eye:
Right Eye:
Eyeglasses: ( ) Y ( )N 10. Digestive System:
3. Ears:
11. Genito-Urinary:
Hearing:
Left Ear:
12. Skin:
Right Ear:
4. Nose:
5. Mouth:
14. Extremities:
6. Throat:
7. Neck:
16. Immunization:
8. Respiratory System:
17. Blood Analysis:
Results:
Date Taken:
Blood Type:
18. REMARKS:
19. RECOMMENDATION:
Signature of Patient