REVISED FORM 86

Department of Education
HEALTH AND NUTRITION CENTER

Name: EDUARDO D. QUIDTA JR.

_____________________________________ Region: VI – Western Division: __________
BAGO CITY
Visayas
Date of Birth: JANUARY 04, 1990
_______________________ Place of Birth: ______________
LA CASTELLANA Civil Status: ______
SINGLE
School: _____________________________
RAMON TORRES DULAO NHS Occupation: ____________________
PUBLIC SCHOOL TEACHER Sex: ______
MALE

Age: _________
31 Wt: __________
66Kg. Height: __________
5'6 Temperature: ___________
BP: _____ Pulse Rate ___________________ Respiratory Rate: ___________

Date of Examination: _________________________________

Past History:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

PHYSICAL EXAMINATION

Skin: ___________________________________________________________________________________
ENT: ___________________________________________________________________________________
Chest: ___________________________________________________________________________________
 Heart: _________________________________________________________________________________
 Lungs: _________________________________________________________________________________
Abdomen: _________________________________________________________________________________
Genito Urinary Tract: ____________________________________________________________________
Extremities: ________________________________________________________________________________
Central Nervous System: _____________________________________________________________________

LABORATORY EXAMINATION

Chest X-ray: ________________________________________________________________________________

Urinalysis: _________________________________________________________________________________
Fecalysis: _________________________________________________________________________________
Other Lab Exams: ___________________________________________________________________________

DIAGNOSIS: ____________________________________________________________________________

TREATMENT: ____________________________________________________________________________

REMARKS: ____________________________________________________________________________

______________________________
EDUARDO D. QUIDTA JR. ______________________________
Employee’s Signature Physician’s Signature
(over printed name) (over printed name)