Name: Bureau of Public School, Department of Education
Date of Birth: Date:
1. Date: Age: Height:
2.Temperature Weight: 3. Respiratory System Sputum Analysis 4. Circulatory System Blood Pressure: Systolic: Diastolic: Pulse: Sitting: Agility test: After 3 min. Blood Analysis 5. Digestive System 6. Genito-Urinary Urinalysis, etc. 7. Skin 8. Loco-Motor System 9. Nervous System 10. Eye-Conj. Etc. 11. Color Perception: 12. Vision w/o glasses (Right) Far: Near: (Left)Far: Near: with glasses (Right) Far: Near: (Left)Far: Near: 13. Ears 14. Hearing Right Ear: Left Ear: 15. Nose 16. Throat 17. Teeth and Gum 18. Immunization Date 19. Remarks
20. Recommendation
21. Emloyee's Signature:
22. Physicians Signature:
INSTRUCTION FOR FILLING
1. Record main activity and not official designation
Example: Letter.Carrier, Messenger,Telephone Opeartor,Typist etc. 2. Include Larynx,Broncho and lungs indicate necessity for x-ray and laboratory examination when needed and cannot be done due to lack of facilities. Record important history and abnormal findings 3. Include Examination to Hernia , arms, inflammation of the gallbladder,appendix and assignment of the spleen. 4. Indicate necessity for Laboratory examination due to lack of facilities 5. Include test for flexibility of joint and reflexes 6. Record important history and abnormal findings, Test for Arrol Robertson and member's sing. 7. Indicate necessity for special examination if symptoms warrant and no facilities are available 8. Use ordinary conversation voice and 6 meters test one ear at a time.Read abnormality as slight, moderate,severe or total deafness 9. Look especially for Diarrhea 10. Record other abnormal findings, temporary or permanent, unfitness, for work contagious condition, etc. 11. Record date of immunization against cholera,dysentery and typhoid. 12. Record if employee needs medical treatment,vacation,separation from service or improvement of certain habits 13. Employee must sign in the presence of examining Physician
NOTE: All entries must be written in ink. Any correction must be signed over by the physician.
Jacques Berlinerblau The Vow and The Popular Religious Groups of Ancient Israel A Philological and Sociological Inquiry JSOT Supplement Series 1996 PDF