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    CS-FORM-86-Medical-Certificate

    Uploaded by

    Desiree Rosete Beringa-Caasi

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    © All Rights Reserved
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    CS-FORM-86-Medical-Certificate

    Uploaded by

    Desiree Rosete Beringa-Caasi
    0 views2 pages

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    © © All Rights Reserved

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    0 views2 pages

    CS-FORM-86-Medical-Certificate

    Uploaded by

    Desiree Rosete Beringa-Caasi

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    REVI

    SEDFORM 86

    Depar
    tmentofEducat
    ion
    HEALTHANDNUTRI
    TIONCENTER

    Name: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___ Regi
    on: NCR Di
    vi
    sion: Mani
    l
    a

    Dat
    eofBi
    rt
    h: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _ Pl
    aceofBi
    rt
    h: _
    ___
    ___
    ___
    ___
    _ Ci
    vi
    lSt
    atus: _
    ___
    __

    School
    : _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _ Occupat
    ion: _
    ___
    ___
    ___
    ___
    ___
    ___
    _ Sex: _
    ___
    __

    Age: _
    ___
    ___
    __ Wt
    :__
    ___
    ___
    __ Hei
    ght
    :__
    ___
    ___
    __ Temper
    atur
    e: _
    ___
    ___
    ___
    _

    BP: _
    ___
    _ Pul
    seRat
    e _
    ___
    ___
    ___
    ___
    ___
    ___ Respi
    rat
    oryRat
    e: _
    ___
    ___
    ___
    _

    Dat
    eofExami
    nat
    ion: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    PastHi
    stor
    y:

    _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    PHYSI
    CALEXAMI
    NATI
    ON

    Ski
    n: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    ENT: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    Chest
    : _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    Hear
    t: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    Lungs: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    Abdomen: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    Geni
    toUr
    inar
    yTr
    act
    : _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    Ext
    remi
    ti
    es: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _

    Cent
    ralNer
    vousSy
    stem: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    LABORATORYEXAMI
    NATI
    ON

    ChestX-
    ray
    : _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    _
    Ur
    inal
    ysi
    s: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    Fecal
    ysi
    s: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    Ot
    herLabExams: ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬_
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ______
    __

    DI
    AGNOSI
    S: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___

    TREATMENT: ____________________________________________________________________________

    REMARKS: _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___

    _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __ _
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    ___
    __

    Empl
    oyee’
    sSi
    gnat
    ure Phy
    sici
    an’
    sSi
    gnat
    ure
    (
    overpr
    int
    edname) (
    overpr
    int
    edname)

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