Enclosure to Div. Memo No.

6, s, 1967
General Form 86

HEALTH EXAMINATION RECORD

NAME: Department: Department of Education

Date of Birth: Sex:
Civil Status: Type of Work: Teaching

1. Date: ___________ Date:___________ Height:________ Date: _________Weight:_______

2. ___________Age:______Weight:_______Age:________Height:_________
3. Respiratory System
4. Sputum Analysis
5. Circulatory System
Blood Pressure Systolic_________Diastolic_________Sys___________Dias____________
Pulse__________ Sitting_________Agility_____________
6. Digestive System
7. Genito-Urinary____________________ ________________________ ________________
8. Skin_____________________ ________________________ ________________________
9. Locomotor System__________________ _____________________ __________________
10. Nervous System____________________ ___________________ ___________________
11. Eyes, Conjunction, etc.__________________ ___________________ ________________
12. Color Perception ____________________ ___________________ ___________________
13. Vision: Without glasses Far__________________ Near______________ Far __________
14. Ears ________________________________________________________________________
15. Hearing ______________________Right Ear__________________ Left Ear ____________
Left Ear___________________ Right Ear ___________
16. Nose _________________________ __________________________ ___________________
17. Throat_______________________ __________________________ ___________________
18. Teeth and gums_______________ __________________________ ___________________
19. Immunization ________________ __________________________ ___________________
Date:______________________________________________
20. Recommendations: ____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Employee’s Name (PRINT):_____________________________

Employee’s Signature: ________________________________
Physician’s Name (PRINT):_____________________________
Physician’s Signature ________________________________