CS Form 86 HEALTH EXAMINATION RECORD

Name: ________MARY JOY D. DE LA CRUZ__________ Division: _____NEGROS OCCIDENTAL_________________

Department: ______TLE DEPT.___________________

Date of Birth: ________JANUARY 6, 1977______________

Type of Work: ________TEACHING________________ Sex: __FEMALE___ Civil Status: __MARRIED________

Date: Date: Date:

1 Height: Height: Height:

Weight: Weight: Weight:

2 Temperature:

Respiratory System:
3 Fluorography:

Sputum Analysis:

Ciculatory 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:
10
Conjunctivitis,etc.: Color Perception:

Vision:
11 With glasses: Far: _____ Near: _____ With glasses: Far: _____ Near: _____ With glasses: Far: _____ Near: _____

W/out glasses: Far: _____ Near: _____ W/out glasses: Far: _____ Near: _____ W/out glasses: Far: _____ Near: _____

12 Nose:

13 Ear:

Hearing:
14
Right: Left: Right: Left: Right: Left:

15 Throat:

16 Teeth & Gums:

17 Immunization:

18 Remarks

19 Recommendation

Employee's Signature:
20
Employee's Name (Print):

Physician's Signature:
21
Physician's Name (Print):
 Appendix 11
TEACHER'S HEALTH CARD
Date: _____________________________________________
Name: ____MARY JOY D. DE LA CRUZ__________________
School/District/Division: Hinigaran NHS/Hinigaran 1/Div. of Neg. Occ.
Position/Designation: _____TEACHER 1________
First Year in Service: ______June 5, 2017____________

Family History: (pls. check) Y N Specify Relationship

Hypertension
Cardiovascular Disease
Diabetes Mellitus
Kidney Disease
Cancer
Asthma
Allergy
Other Remarks: ____________________________________________________________________________________
____________________________________________________________________________________
Past Medical History: (check)
Y N Y N
Hypertension Tuberculosis
Asthma Surgical Operations (pls. specify)
Diabetes Mellitus Yellowish discoloration of skin.sclera
Cardiovascular Disease Last hospitalization (reason)
Allergy (pls. specify) ____________________ Others (pls.sprcify) _________________________________

Last Taken Date Result Date Result

CXR/Sputum Result: ______ ______ Drug Testing: ______ ______
ECG ______ ______ Neuropsychiatric exam: ______ ______
Urinalysis ______ ______ Blood Typing: ______ ______
Others (pls.sprcify) _________________________________
Social History
Smoking Y _____ N _____Age started: ____ Sticks/pakcs per day: _____ Packs per year: ______
Alcohol Y _____ N ____ How often: ____________ Food preference: _____________________
OB Gyn History (pls. encircle) (Female Teachers)
Menarche: _______________ Cycle: _____________ Duration _________________________
Parity: F P A L
Papsmear done: Y N if YES, When: _____________________
Self Breast examination done: Y N
Mass noted: Y N Specify where ____________________
For Male personnel: Digital examination done: Y N Date examined: ________ Result: _________________
Present Health Status (pls. check) Y N Y N
Cough 2wks 1mo. longer
Dizziness Lumps
Dyspnea Painful urination
Chest/Back pain Poor/loss of hearing
Easy fatigability Syncope/fainting
Joint/extrimity pains Convulsions
Blurring of vision Malaria
Wearing eyeglasses Goiter
Vaginal discharge/bleeding Anemina
Dental Status: (pls. specify) _______________________________ Others: (pls. specify) ___________________________
Present Medication taken: (pls. specify) ____________________________________________________________________

Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis

ECG - Electro Cardiogram F - Full Term
Y- Yes P - Pre-mature
N- No A - Abortion
HPN - Hypertension L - Live Birth
CVD - Cardio Vascular Disease
DM - Diabetes Mellitus

Interviewed by: ________________________________

Date: _________________________________________
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