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Health Examination Record: Form 86 (Rev. 7/6/69)

This document appears to be a health examination record form from the Republic of the Philippines Department of Education CARAGA Region Division of Butuan City. The form includes sections to record information about a person's name, birthdate, height, weight, temperature, and examination of their respiratory, circulatory, digestive, genitourinary, locomotor, nervous, skin, eyes, ears, nose, throat, teeth and gums, immunizations, and any remarks or recommendations. The employee and physician would sign the bottom of the form to verify the health examination.

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Licca Argallon
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499 views1 page

Health Examination Record: Form 86 (Rev. 7/6/69)

This document appears to be a health examination record form from the Republic of the Philippines Department of Education CARAGA Region Division of Butuan City. The form includes sections to record information about a person's name, birthdate, height, weight, temperature, and examination of their respiratory, circulatory, digestive, genitourinary, locomotor, nervous, skin, eyes, ears, nose, throat, teeth and gums, immunizations, and any remarks or recommendations. The employee and physician would sign the bottom of the form to verify the health examination.

Uploaded by

Licca Argallon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Health Examination Record

Form 86

(Rev. 7/6/69)

Republic of the Philippines


Department of Education
CARAGA REGION
DIVISION OF BUTUAN CITY

HEALTH EXAMINATION RECORD

Name: ______________________________ Sex: _____ Civil Status: _________


Place of Birth: ____________________________ School Assigned: ________________________
Date of Birth: _____________________________ Type of Work: ___________________

1. Date: _________________ Age: _______ Height: ______ Weight: _______


2. Temp: ________________
3. Respiratory System:
4. X-Ray Film No. __________________________________ Date: ____________________
Right Lung: _____________________________________
Left Lung: ______________________________________
Mediastinum: ___________________________________
Impression: _____________________________________
Recommendation: ________________________________
5. Circulatory System :
Blood Pressure: ___________________ Systolic: ________________ Diastolic: ________
Pulse: __________ Sitting: _________________ Agility Test after 5 min. : _____________
Blood Analysis: _________________________________
6. Digestive System: _______________________________
7. Genito/Urinalysis: ______________________________________________
8. Loco Motor System: ____________________________________________
9. Nervous System: _______________________________________________
10. Skin: ________________________________________________________
11. Eyes, Conjunction: _____________________________________________
12. Color Perception: ______________________________________________
13. Vision,w/, w/o glasses: _________________________________________
14. Ears: ________________________________________________________
15. Hearing: _____________________________________________________
16. Nose: _______________________________________________________
17. Throat: ______________________________________________________
18. Teeth and Gums: ______________________________________________
19. Immunization : ________________________________________________
20. Remarks: ____________________________________________________
21. Recommendation: ________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
22. Employee’s Signature: ______________________________
23. Physician’s Signature: ______________________________

Checked by:

____________________________________
District Nurse

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