Republic of the Philippines

Department of Education
REGION XI
SCHOOLS DIVISION OF DAVAO ORIENTAL

General Form 86
HEALTH EXAMINATION RECORD

NAME: ____________________________ DEPARTMENT: Department of Education

SCHOOL: ______________________________ DISTRICT: __________________________
DATE OF BIRTH: ___________________ SEX: _________ CIVIL STATUS: _________

1. Date: __________Height: _____________ Weight: _________ BMI: ________

2. Temperature: _______________________________________________________________
3. Respiratory System: ________________________________________________________
4. Fluorography Result: _____________________________ Where: __________________
(Chest X-ray) Film #: __________________________Date Taken: ________________
Sputum Analysis: ___________________________
5. Circulatory System: ____________________ Blood Pressure: ________________
6. Digestive System: ________________________________________________________
7. Genitourinary: ___________________________________________________________
8. Urinalysis: _______________________________________________________________
9. Skin: _____________________________________________________________________
10. Locomotor: ______________________________________________________________
11. Nervous System: ________________________________________________________
12. Eyes, Conjunctiva, etc.: _________________________________________________
13. Color Perception: ________________________________________________________
14. Vision: With Glasses: Far: _____________________ Near: _______________
Without Glasses: Far: ______________ Near: ______________________
15. Nose: ____________________________________________________________________
16. Ear: ___________________________________________________________________
17. Hearing: ______________________________________________________________
18. Throat: _______________________________________________________________
19. Immunization: _______________________________________________________
20. Teeth and Gums: _____________________________________________________
Recommendation: ________________________________________________________

21. Employee’s Signature: ___________________________________________________

22. Employee’s Printed Name: _______________________________________________

23. Physician’s Signature: ___________________________________________________

24. Physician’s Name: ____________________________ License No.: _____________

“GOVERNANCE THROUGH EXCELLENCE WITH INTEGRITY ANYTIME, ANYWHERE”

Address: Government Center, Dahican, Mati City, Davao Oriental

Telephone Number: (087) 388-3372 ISO 9001:2015
CERTIFIED