CASA MARIE LEARNING INSTITUTE INC.

Pancil, Obogon, Tanjay City

School Health
HEALTH EXAMINATION RECORD
Name: ___________________________________________________________________________ Office: ________________________________

Address: ____________________________________________________________________ Type of Work: _________________________

Age: __________ Sex: ________ Civil Status: ______________ Height: __________ Weight: ____________

1. Respiratory System: 8. Eyes: _____________________________________

______________________________ Color Perception: ________________________

Fluoroscopy: ___________________ Vision Test – Distant Vision:

Right Lung: _____________________ w/o glasses – Right Eye: ___________________________

2. Circulatory System: Left Eye: ______________________________

____________________________ w/glasses – Right Eye: ________________________________

Blood Pressure: Left Eye: __________________________________

Systolic: _______________________ Vision Test - Near Vision:

Diastolic: ______________________ w/o glasses - Right Eye: _____________________________

Pulse: ________________________ Left Eye: _________________________________

Sitting: _______________________ w/glasses – Right Eye: ________________________________

Agility Test: ___________________ Left Eye: __________________________________

After 2 mins: __________________ 9. Ears: _____________________________________

3. Digestive System Hearing – Right Ear: __________________

_____________________________ Left Ear: ___________________
_____________________________ Ticking of Watch – Right Ear: ___________________________
_____________________________ Left Ear: _____________________________
4. Genite – Urinary: Communication – Right Ear: ___________________________
_____________________________ Left Ear: _____________________________
_____________________________ 10. Nose:
_____________________________ ________________________________________________
Urinalysis: ________________________________________________
_____________________________ ________________________________________________
_____________________________ 11. Threat:
_____________________________ ________________________________________________
5. Skin
_____________________________ ________________________________________________
_____________________________ ________________________________________________
_____________________________ 12. Teeth:
6. Locomotor System ________________________________________________
_____________________________ ________________________________________________
_____________________________ ________________________________________________
_____________________________ 13. Gums:
7. Nervous System: ________________________________________________
_____________________________ ________________________________________________
_____________________________ 14. REMARKS:
_____________________________ ________________________________________________
_________________________________________________
RECOMMENDATION:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
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Date:
CASA MARIE LEARNING INSTITUTE INC.
Pancil, Obogon, Tanjay City
School Clinic
DENTAL RECORD

Name: _______________________________________ Age: ____ Gender: ____ Birthdate: ________________

Address: _______________________________________________________ Destination: _____________________________________________

Contact Person ( In case of emergency) _________________________________________________ Contact:
______________________