Form 86 HEALTH EXAMINATION RECORD

Name: ______________________________________________ Division :____________________________________ School : _____________________________________________ District : _________________________

Date of Birth: ______________________________________ Type of Work: ______________________________ Age/Sex: ___________________ Civil Status: _____________________
1 Date: (mm/dd/yyyy) - / / 2022 Date: (mm/dd/yyyy) - / / 2023 Date: (mm/dd/yyyy) - / / 2024
Height : cm Height : cm Height : cm
2 Weight : kgs Weight : kgs Weight : kgs
Temperature : Temperature: Temperature:
Respiratory System: Respiratory System: Respiratory System:
3 Fluorography Fluorography Fluorography
Sputum Analysis Sputum Analysis Sputum Analysis
Circulatory System: Circulatory System: Circulatory System:
Blood Pressure: / mmHg BP: / mmHg BP: / mmHg
4
Pulse: Pulse: Pulse:
Sitting: Agility test: Sitting: Agility test: Sitting: Agility test:
5 Digestive System: Digestive System: Digestive System:
Genito-Urinary: Genito-Urinary: Genito-Urinary:
6
Urinalysis: Pus Cells ___________ RBC ___________ Urinalysis: Pus Cells ___________ RBC ___________ Urinalysis: Pus Cells ___________ RBC ___________
7 Skin: Skin: Skin:
8 Locomotors System: Locomotors System: Locomotors System:
9 Nervous System: Nervous System: Nervous System:
Eyes: Conjunctivitis: Others: Eyes: Conjunctivitis: Others: Eyes: Conjunctivitis: Others:
10
Color Perception: Color Perception: Color Perception:
Vision: Vision: Vision:
11 With Glasses Far Near With Glasses Far Near With Glasses Far Near
Without Glasses Far Near Without Glasses Far Near Without Glasses Far Near
12 Nose: Nose: Nose:
13 Ear: Ear: Ear:
14 Hearing: Hearing: Hearing:
Right: Left: Right: Left: Right: Left:
15 Throat: Throat: Throat:
16 Teeth & Gums: Teeth & Gums: Teeth & Gums:
17 Immunization: Immunization: Immunization:
18 Remarks: Remarks: Remarks:
19 Recommendation: Recommendation: Recommendation:
Employee’s Signature: Employee’s Signature: Employee’s Signature:
20
Employee’s Print Name: Employee’s Print Name: Employee’s Print Name:
Assisted by: Assisted by: Assisted by:
21
PRINCESS R. APARIS, RN PRINCESS R. APARIS, RN PRINCESS R. APARIS, RN
Physician Signature: Physician Signature: Physician Signature:
22
Physician’s Name: DR. ANGELICA C. RODRIGUEZ Physician’s Name: DR. ANGELICA C. RODRIGUEZ Physician’s Name: DR. ANGELICA C. RODRIGUEZ