REVISED FORM 86

Department of Education
SCHOOL HEALTH AND NUTRITION SECTION

Name: Region: Division:

Age: Birthday: Place of Birth: Civil Status:

School: Position: Sex:

Age: Wt: Ht: BMI: 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
CBC and Blood Chem
Chest X-ray
ECG
Urinalysis
Other Lab Exams

DIAGNOSIS:

TREATMENT:

REMARKS: FIT OR NOT FIT TO WORK

Employee’s Signature Physician’s Signature

(over printed name) (over printed name)
PRC LIC#

Hospital or Clinic Name and Address