TEACHER'S ANNUAL HEALTH EXAMINATION RECORD

CSC Form 86
NAME: __________________________________________ DATE OF BIRTH: _____________
SCHOOL: ________________________________________ GENDER: ___________________
ADDRESS: _______________________________________ CIVIL STATUS: _______________
POSITION: ____________________________
DATE OF APPOINTMENT: _____________________________
DATE:
Height
Weight
Temperature
Respiratory
Circulatory
Blood Pressure
Pulse Rate
Digestive System
Genital/Urinal
Skin
Loan-motor Sysyten
Nervous System
Eye Conjunctive
Color Perception
Vision w/out Glasses
Vision w/Glasses
Ears
Hearing
Nose
Throat
Teeth/Gums
Immunization
Laboratory Examination
X-ray
Urinalysis
Papsmear
Others:

REMARKS:

PHYSICIAN SIGNATURE PHYSICIAN SIGNATURE

Note: All Entries must be written in ink. Any erasure must be signed by the physician.