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  • General Form 86

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    Aprille Oliveros
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    This document is a health examination record form from the Department of Education in Region X of the Philippines. The form collects personal information about an individual such as name, date of birth, contact details, and employment details. It then documents the results of a physical examination covering 25 bodily systems and functions including height, weight, blood pressure, vision, hearing, immunizations and more. The form concludes with an area for remarks by the examining physician and their recommendations.

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    GENERAL-FORM-86

    Original Title

    GENERAL-FORM-86

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    This document is a health examination record form from the Department of Education in Region X of the Philippines. The form collects personal information about an individual such as name, date of birth, contact details, and employment details. It then documents the results of a physical examination covering 25 bodily systems and functions including height, weight, blood pressure, vision, hearing, immunizations and more. The form concludes with an area for remarks by the examining physician and their recommendations.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    25 views1 page

    General Form 86

    Uploaded by

    Aprille Oliveros
    This document is a health examination record form from the Department of Education in Region X of the Philippines. The form collects personal information about an individual such as name, date of birth, contact details, and employment details. It then documents the results of a physical examination covering 25 bodily systems and functions including height, weight, blood pressure, vision, hearing, immunizations and more. The form concludes with an area for remarks by the examining physician and their recommendations.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
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    Republic of the Philippines

    Department of Education
    REGION X – NORTHERN MINDANAO
    SCHOOLS DIVISION OF OZAMIZ CITY

    GENERAL FORM 86

    HEALTH EXAMINATION RECORD

    NAME:_________________________________________Department:_______________________
    Place of Birth:___________________________________ Date of Birth ______________________
    Civil Status: _______________________ Sex: _________ Type of Work:_____________________
    School:_____________________________District:_______Contact#_________________________
    PHILHEALTH#_____________________________________Date:__________________________

    1. Age: ______________ Height: _________cm. Weight : ____________ kg. BMI: _____________


    2. Temperature : ______________ Pulse: ___________bpm Respiratory Rate:_________________
    3. Respiratory System: ____________________________ O2 Saturation: _____________________
    4. Chest X - Ray : __________________________________ Date taken: _____________________
    5. Sputum : ______________________________________________________________________
    6. Circulatory System: _____________________________________________________________
    7. Blood Pressure : _______________________Systole : ____________ Diastole :_____________
    8. Drug Test : ________________________________ Date Examined: ____________
    9. Blood Analysis : _________________________________ Date taken: ____________________
    10. Digestive System : _____________________________________________________
    11. Genital Urinary : _______________________________________________________________
    12. Urinalysis : _____________________________________Date Examined: __________________
    13. Skin : _________________________________________________________________________
    14. Locomotor: ____________________________________________________________________
    15. Nervous System : _______________________________________________________________
    16. Eyes conjunctiva : ______________________________________________________________
    17. Color perception : ______________________________________________________________
    18. Vision : Without eyeglasses : ______________________ With eyeglasses: _________________
    19. Ears : ________________________________________________________________________
    20. Hearing :________________ Right ear: __________________ Left ear: ___________________
    21. Nose : ________________________________________________________________________
    22. Throat : _______________________________________________________________________
    23. Teeth and Gums : _______________________________________________________________
    24. Immunization :_________________________________________________________________
    25. Blood Type : “_______”
    26. Neuropsychiatric Examination :___________________________________________________
    __________________________________________________________________________________________

    Date examined: _______________


    REMARKS : _________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    RECOMMENDATION : _______________________________________________
    ____________________________________________________________________
    ____________________________________________________________________

    ______________________
    (Signature of Employee)
    ______________________
    Government Physician

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