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  • FORM 86 Annual Health Records

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    CHARMAINE GRACE BALUTAN
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    This document contains a health examination record for an individual. It records their personal details, measurements, and assessments of various body systems. The respiratory, circulatory, digestive, genito-urinary, skin, loco-motor, and nervous systems were all examined. Vision, hearing, and dental health were also assessed. Vaccination history for Covid-19 was noted. The physician provided an overall recommendation and signed the document.

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    This document contains a health examination record for an individual. It records their personal details, measurements, and assessments of various body systems. The respiratory, circulatory, digestive, genito-urinary, skin, loco-motor, and nervous systems were all examined. Vision, hearing, and dental health were also assessed. Vaccination history for Covid-19 was noted. The physician provided an overall recommendation and signed the document.

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    Download as doc, pdf, or txt
    3 views1 page

    FORM 86 Annual Health Records

    Uploaded by

    CHARMAINE GRACE BALUTAN
    This document contains a health examination record for an individual. It records their personal details, measurements, and assessments of various body systems. The respiratory, circulatory, digestive, genito-urinary, skin, loco-motor, and nervous systems were all examined. Vision, hearing, and dental health were also assessed. Vaccination history for Covid-19 was noted. The physician provided an overall recommendation and signed the document.

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    © All Rights Reserved
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    of 1

    General Form 86

    DepEd- SDO, Surigao City

    HEALTH EXAMINATION RECORD

    Name: _________________________________________ Contact No:____________________


    School: ______________________________ District_____ Designation/Position:___________
    Date of Birth: ________________________ Sex: ____ Age: _______ Civil Status: __________
    Date examined: ____________________ Height: _______ Weight: ________ BMI ________
    Respiratory System: ____________________________________________________________
    Circulatory System: ____________________________________________________________
    Blood Pressure: _____________ Systolic:________ Diastolic:________ O2 Sat_______
    Pulse Setting: _________________ Agility Test: ___________After 3 mins:________
    Digestive System: _______________________________________________________________
    Genito-Urinary System: _________________________________________________________
    Urinalysis, etc: ___________________________________________________________
    Skin: _________________________________________________________________________
    Loco-Motor System: ____________________________________________________________
    Nervous System: _______________________________________________________________
    Eyes: Conjunctiva: etc: _________________________________________________________
    Color Perception: ______________________________________________________________
    VISION Without glasses Far: _______________ Near: _______________________
    With glasses Far: _______________ Near: _______________________
    Ears: _________________________________________________________________________
    Hearing: _____________________ Right Ear: ________________ Left Ear: ______________
    Nose: _________________________________________________________________________
    Throat: _______________________________________________________________________
    Teeth and Gum: ________________________________________________________________
    Type of Covid Vaccine__________________ 1st Dose Date____________2nd dose date__________
    Booster Dose Vaccine/ Date___________________________FBS: _______________________
    Fluoroscopy: __________________________________________________________________

    Recommendation: ______________________________________________________________

    Employee’s Signature: ________________________

    ___________________________________
    Physician’s Signature over Printed Name
    License Number: ____________

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