CONSOLIDATED ANNUAL PHYSICAL EXAMINATION & LABORATORY RESULTS OF DEPED EMPLOYEES

(TP/NTP)
CY 2019
District:______________________________________ Name of School:__________________________________
Urinalysis Chest X-ray Physician’s
NAME OF TEACHER TP/ Finding (from
NTP Form 86)
Date PC Sugar Albumin Others Date Result Remarks

Prepared by: Noted:

________________________________ ________________________________________
Clinic Teacher/District Nurse PSDS/DPIC/TIC/SH/SP

Note: Teacher’s annual Health Examination Form 86 must be filled out by the Licensed Physician.