Republic of the Philippines

Department of Education
REGION XI
SCHOOLS DIVISION OF DAVAO ORIENTAL

General Form. 86

HEALTH EXAMINATION RECORD

NAME: MARY GRACE M. ARABILLA DEPARTMENT: EDUCATION

SCHOOL: Manuel B. Guinez Sr. National High School DISTRICT: Banaybanay
DATE OF BIRTH: JANUARY 23, 1986 SEX: FEMALE CIVIL STATUS: MARRIED

1. Date: Height: Weight: BMI:

2. Temperature:
3. Respiratory System:
4. Fluorography Result: Where:
(Chest X-ray) Film #: Date Taken:
Sputum Analysis:
5. Circulatory System: Blood Pressure:
6. Digestive System:
7. Genitourinary:
8. Urinalysis:
9. Skin:
10. Locomotor:
11. Nervous System:
12. Eyes, Conjunctiva, etc.:
13. Color Perception:
14. Vision: With Glasses: Far: Near:
Without Glasses: Far: Near:
15. Nose:
16. Ear:
17. Hearing:
18. Throat:
19. Immunization:
20. Teeth and Gums:
Recommendation:

21. Employee’s Signature:

22. Employee’s Printed Name:

23. Physician’s Signature:

24. Physician’s Name: License No.:

“GOVERNANCE THROUGH EXCELLENCE WITH INTEGRITY ANYTIME, ANYWHERE”

Address: Government Center, Dahican, Mati City, Davao Oriental ISO 9001:2015
Telephone Number: (087) 388-3372 CERTIFIED