GENERAL FORM 86

HEALTH EXAMINATION RECORD

Name: ______________________________________________ Bureau: _______________________________

Department: ________________________________________ Date of Birth: __________________________
Civil Status: _______________________________________ Type of Work: __________________________
1. Date: ________________ Date: ____________________ Height: _____ Date: ________ Height: ______
Age: _____________________ Weight: ____ Date: ________ Weight: ______
2. Temperature : ______________________________________________________________________________
3. Respiratory System Pulse : _______________________________________________________________________
4. Digestive System : _____________________________________________________________________________
5. Genite - Urinary : ______________________________________________________________________________
6. Skin : _______________________________________________________________________________________
7. Locomotor System : ____________________________________________________________________________
8. Nervous System : ______________________________________________________________________________
9. Eye : Conjuctice etc : ____________________________________________________________________________
10. Color Perception : _____________________________________________________________________________
11. Vision w/o glasses : ___________________________________________________________________________
12. Ears : _____________________________________________________________________________________
13. Hearing : ___________________________________________________________________________________
14. Nose : _____________________________________________________________________________________
15. Throat : _____________________________________________________________________________________
16. Teeth and Gums : _____________________________________________________________________________
17. Immunization : _______________________________________________________________________________
18. Remarks : __________________________________________________________________________________
19. Flouroscopy : ________________________________________________________________________________
20. Recommendation : ____________________________________________________________________________
21. Employee's Physician
Signature : ___________________________________ Signature : ________________________________

Instructions for Filling

1. Record main activity and the official designation. Example : Letter Carrier, telephone operator, typist, executive etc.
2. Include larynx, bronchi and lungs. Indicate necessary for X-ray and laboratory examination when needed and
cannot be done due to lack of facilities.
3. Include examination for hernia, inflammation of the gall bladder, appendix and enlargement of the spleen.
4. Include test for respiration power of the heat and blood pressure.
5. Indicate the necessity for laboratory examination when needed cannot be done for reason of sex record,
" not examined ".
6. Include test for flexibility of joint reflexes.
7. Record important history and abnormal findings, test for Argy Robertson and Embergs disease.
8. Indicate necessity for specialist examination if sympton warrant and no facilities available.
9. Use ordinary conversational voice at 56 meters. The ear at a time. Record abnormality or slight, moderate, severe
or total deafness.
10. Record the date of immunization against malaria, dysentery and typhoid.
11. Look especially for pyorrhea.
12. Record other abnormal findings, temporary or permanent unfitness for work, contagious etc.
13. Record if employee needs medical treatment, vacation, separation from the service or improvement of
certain habit.
14. Employee must sign in the presence of the examining physician.

NOTE: All entries must be written in ink. Any erasure or correction must be sign by the physician.