Scribd
Upload
121 views4 pages

Form 5

This document contains a teacher's health examination record form with sections for recording measurements of height, weight, blood pressure, vision, hearing, and other health metrics over multiple dates. The form also includes spaces for noting examination findings of various body systems and organs, immunization history, physician remarks and recommendations, and signatures of the employee and examining physician.

Uploaded by

Jenny Rose Velasquez Pagaduan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
121 views4 pages

Form 5

This document contains a teacher's health examination record form with sections for recording measurements of height, weight, blood pressure, vision, hearing, and other health metrics over multiple dates. The form also includes spaces for noting examination findings of various body systems and organs, immunization history, physician remarks and recommendations, and signatures of the employee and examining physician.

Uploaded by

Jenny Rose Velasquez Pagaduan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
You are on page 1/ 4

2018 SHD Form 5

TEACHER'S HEALTH EXAMINATION RECORD


Name: Division: Department:
Date of Birth: Type of Work: Sex: Civil Status:

1 Date: Date: Date:


Height Height Height
Weight Weight Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: __________ Near: _________ With glasses: Far: __________ Near: _________ With glasses: Far: __________
Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________ Without glasses: Far: __________
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left: Right: Left:
2018 SHD Form 5

15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee's Signature:
Employee's Name (Print):
21 Physician's Signature:
Physician's Name (Print):
2018 SHD Form 5

TH EXAMINATION RECORD

Civil Status:

Agility Test:

Far: __________ Near: _________


Far: __________ Near: _________
2018 SHD Form 5

You might also like