CS FORM 86 HEALTH EXAMINATION RECORD

Name: SHERWIN P. AMORES Division: PAGADIAN CITY

Department: DEPARTMENT OF EDUCATION_______

Date of Birth: MARCH 24, 1981 Type of Work: TEACHING

Sex: MALE Civil Status: MARRIED________
Date: Date: Date:
1 Height Height Height
Weight Weight Weight
2 Temperature:
Respiratory System:
3 Fluorography:
Sputum Analysis:
Circulatory System:
Blood Pressure:
4 Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility
Test:
5 Digestive System:
Genito-Urinary:
6
Urinalysis, etc.:
7 Skin:
8 Locomotor System:
9 Nervous System:
Eyes: Conjunctivitis, etc.:
10
Color Perception:
Vision:
With glasses: Far: With glasses: Far: With glasses: Far:
11 Near: Near: Near:
Without glasses: Far: Without glasses: Far: Without glasses: Far:
Near: Near: Near:
12 Nose:
13 Ear:
Hearing:
14
Right: Left: Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks:
19 Recommendation:
Employees Signature
20
Employees Name (Print)
21 Physicians Signature
Physicians Name (Print)