CS Form 86

HEALTH EXAMINATION RECORD

Name: ____________________________________________ Division: SIQUIJOR 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:
Flourography: _______________________________ Flourography: _______________________________ Flourography: _______________________________
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): ________________________________