Republic of the Philippines

Department of Education
Region X
DIVISION OF BUKIDNON
Sumpong, Malaybalay City

Form No. 86
PHYSICAL AND MEDICAL HEALTH RECORD

Name: Position:
School: District:
Age: Sex: Civil Status: Contact No:
Birthplace: Race/Ethnicity:
Permanent Address:

DATE EXAMINED:

1. Vital Signs:
Temperature: °C
Chest X-Ray / Sputum Exam
BMI: ( )
Result:
Height: cm Weight: kg
PR: bpm RR: cpm Date Taken:
2. Eyes/Conjunctiva:

Color Perception:

9. Circulatory System:
Vision:
VA of: Left Eye:
Right Eye:
Eyeglasses: ( ) Y ( )N 10. Digestive System:

3. Ears:

11. Genito-Urinary:

Hearing:
Left Ear:
12. Skin:
Right Ear:
4. Nose:

13. Back and Spine:

5. Mouth:

14. Extremities:

6. Throat:

15. Nervous System:

7. Neck:

16. Immunization:
8. Respiratory System:
17. Blood Analysis:
Results:

Date Taken:

Blood Type:
18. REMARKS:

19. RECOMMENDATION:

Signature of Patient

Medical Officer / Government Physician

License Number: