Republic of the Philippines

Department of Education
REGION VII-CENTRAL VISAYAS
SCHOOLS DIVISION OF NEGROS ORIENTAL

HEALTH EXAMINATION RECORD

NAME: SD SD SCHOOL/STATION: L
DATE OF BIRTH: U 91 TYPE OF WORK: T SEX:F FF CIVIL STATUS: S E
Date: Date: Date:
Height: ________ Weight: _______ Height: ________ Weight: _______ Height: ________ Weight: _______
Temperature Temperature Temperature
Respiratory System: Respiratory System: Respiratory System:
Fluorography:______ Sputum Analysis: ___ Fluorography:______ Sputum Analysis: ___ Fluorography:______ Sputum Analysis: ___
Circulatory System: Circulatory System: Circulatory System:
Blood Pressure: _____ 02 Sat: ____ Blood Pressure: _____ 02 Sat: ____ Blood Pressure: _____ 02 Sat: ____
Pulse Rate: ______ Pulse Rate: ______ Pulse Rate: ______
Sitting: __ Agility Test: ____ Sitting: __ Agility Test: ____ Sitting: __ Agility Test: ____
Digestive System: Digestive System: Digestive System:
Genito-urinary: Urinalysis, etc.:__________________ Genito-urinary: Urinalysis, etc.:__________________ Genito-urinary: Urinalysis, etc.:__________________
Skin: Skin: Skin:
Locomotor System: Locomotor System: Locomotor System:
Nervous System: Nervous System: Nervous System:
Eyes: Conjunctivitis, etc: ____ Eyes: Conjunctivitis, etc: ____ Eyes: Conjunctivitis, etc: ____
Color Perception: ______ Color Perception: ______ Color Perception: ______
Vision Vision Vision
With eyeglasses: Far:___ Near:___ With eyeglasses: Far:___ Near:___ With eyeglasses: Far:___ Near:___
W/O eyeglasses: Far:___ Near:___ W/O eyeglasses: Far:___ Near:___ W/O eyeglasses: Far:___ Near:___
Nose: Nose: Nose:
Ear: Ear: Ear:
Hearing: Right ___ Left: ___ Hearing: Right ___ Left: ___ Hearing: Right ___ Left: ___
Throat: Throat: Throat:
Teeth and Gums: Teeth and Gums: Teeth and Gums:
Immunizations: Immunizations: Immunizations:
Remarks: Remarks: Remarks:

Recommendations: Recommendations: Recommendations:

Employee’s Signature over Printed Name Employee’s Signature over Printed Name Employee’s Signature over Printed Name
 Republic of the Philippines
Department of Education
REGION VII-CENTRAL VISAYAS
SCHOOLS DIVISION OF NEGROS ORIENTAL

Physician’s Signature over Printed Name Physician’s Signature over Printed Name Physician’s Signature over Printed Name