Professional Documents
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Health Examination Record Form 86
Health Examination Record Form 86
Department of Education
Caraga Region 13
SCHOOLS DIVISION OF SURIGAO DEL SUR
Balilahan, Mabua, Tandag City
Revised Form 86
HEALTH EXAMINATION RECORD
NAME: _______________________________________________________________ POSITION: ___________________________________________
SCHOOL: ____________________________________________________________ DISTRICT: ____________________________________________
DATE OF BIRTH: _____________________________ AGE: _______________ SEX: _____________ CIVIL STATUS: ____________________
PRESENT ADDRESS: _________________________________________________________________________________________________________
DATE OF EXAMINATION: ___________________________________________________________________________________________________
Height: _______________________________ Weight: _______________________________ Temperature: ______________________________
Blood Pressure: _______________________________Pulse Rate: __________________________ Heart Rate: _________________________
PAST HISTORY:
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PHYSICAL EXAMINATION:
Skin; __________________________________________________________________________________________________________________________
Eyes: _________________________________________________________________________________________________________________________
Ears: _________________________________________________________________________________________________________________________
Nose: _________________________________________________________________________________________________________________________
Throat: _______________________________________________________________________________________________________________________
Chest: ________________________________________________________________________________________________________________________
Heart: ________________________________________________________________________________________________________________________
Lungs: ________________________________________________________________________________________________________________________
Abdomen: ____________________________________________________________________________________________________________________
Extremities: _________________________________________________________________________________________________________________
Genito-Urinary Tract System: ______________________________________________________________________________________________
Central Nervous System: ___________________________________________________________________________________________________
LABORATORY EXAMS:
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DIAGNOSIS:
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TREATMENT:
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REMARKS:
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