General Form 86

HEALTH EXAMINATION RECORD

Philhealth Number : ______________________

Name: _______________________ Department : _____________________

Date of Birth : ________________ Sex: _______ Age: ______ Civil Status: _______
Date Examined: ______________________ Height: ___________ Weight : ___________________

Type of Work : ____________________________________________________________________

Respiratory System : ________________________________________________________________

Circulatory System: _________________________________________________________________

Blood Pressure: ____________________ Systolic: ________________ Diastolic: ________

Pulse Setting: ______________________ Agility test : _____________ After 3 mins: ______

Digestive System: ___________________________________________________________________

Genito-Urinary System: ______________________________________________________________

Urinalysis, etc: _______________________________________________________________

Skin : _____________________________________________________________________________

Loco-motor System :_________________________________________________________________

Nervous System : ___________________________________________________________________

Eyes: Conjunctiva: etc: _______________________________________________________________

Color perception: ___________________________________________________________________

VISION Without glasses Far:_______________________ Near: __________________

With glasses Far: ______________________ Near : __________________

Ears: _______________________________________________________________________________

Hearing: __________________________ Right Ear ___________________ Left Ear: _______________

Nose : ______________________________________________________________________________

Throat : _____________________________________________________________________________

Teeth and Gum: ______________________________________________________________________

Immunization Date ____________________________________________ FBS: ___________________

Fluoroscopy: _________________________________________________________________________

Recommendation: ____________________________________________________________________

Employee’s Signature: _________________

________________________
Medical Officer