Professional Documents
Culture Documents
Health Card For Teachers
Health Card For Teachers
Other Remarks:
Hypertension [ ] [ ] Tuberculosis [ ] [ ]
Asthma [ ] [ ] Surgical Operations (pls. specify) [ ] [ ]
Diabetes Mellitus [ ] [ ] Yellowish discoloration of skin/sclera [ ] [ ]
Cardiovascular Disease [ ] [ ] Last hospitalization (reason) [ ] [ ]
Allergy (pls. specify) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing: Others specify:
ECG Neuropsychiatric exam:
Urinalysis Blood Typing:
Social History
Smoking Y N Age started: Sticks/packs per day: Packs per year:
Alcohol Y N How often: Food preference:
Date: