Republic of the Philippines

Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR
Balilahan, Mabua, Tandag City
surigaodelsur.division@deped.gov.ph

Revised CS 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:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
DIAGNOSIS:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
TREATMENT:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
REMARKS:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Patient’s/Employee’s Signature: __________________________________________________

Attending Physician’s Signature: Name: ________________________________________

License No.: __________________________________
PTR No.: ______________________________________
Date: __________________________________________