Republic of the Philippines

Department of Education
Region VII, Central Visayas
Division of Cebu Province
Schools Governance and Operations Division - Medical Section

MASTERLIST OF TEACHING / NON-TEACHING PERSONNEL

ANNUAL PHYSICAL CHECK-UP RECORD

DISTRICT: Balamban 1 NAME OF SCHOOL: NO. OF TEACHING

NO OF NON-TEACHING

LABORATORIES RECOMMENDED BY THE PHYSICIAN (IF

DATE OF SPUTUM
NAME OF PERSONNEL URINALYSIS X-RAY CBC
EXAM (PREGNANT)
(FORM 86)
DATE DATE DATE DATE
TAKEN RESULT TAKEN RESULT TAKEN RESULT TAKEN RESULT

LABORATORIES RECOMMENDED BY THE PHYSICIAN (IF

DATE OF SPUTUM
NAME OF PERSONNEL URINALYSIS X-RAY CBC
EXAM (PREGNANT)
(FORM 86) DATE
RESULT
DATE
RESULT
DATE
RESULT
DATE
RESULT
TAKEN TAKEN TAKEN TAKEN
 LABORATORIES RECOMMENDED BY THE PHYSICIAN (IF
DATE OF
URINALYSIS X-RAY SPUTUM CBC
NAME OF PERSONNEL EXAM (PREGNANT)
(FORM 86) DATE
RESULT
DATE
RESULT
DATE
RESULT
DATE
RESULT
TAKEN TAKEN TAKEN TAKEN
 LABORATORIES RECOMMENDED BY THE PHYSICIAN (IF
DATE OF
URINALYSIS X-RAY SPUTUM CBC
NAME OF PERSONNEL EXAM (PREGNANT)
(FORM 86) DATE
RESULT
DATE
RESULT
DATE
RESULT
DATE
RESULT
TAKEN TAKEN TAKEN TAKEN

LABORATORIES RECOMMENDED BY THE PHYSICIAN (IF

DATE OF SPUTUM
NAME OF PERSONNEL URINALYSIS X-RAY CBC
EXAM (PREGNANT)
(FORM 86)
 DATE OF
NAME OF PERSONNEL EXAM
(FORM 86) DATE
RESULT
DATE
RESULT
DATE
RESULT
DATE
RESULT
TAKEN TAKEN TAKEN TAKEN
tion

SONNEL

EACHING PERSONNEL: MALE FEMALE

TEACHING PERSONNEL MALE FEMALE

YSICIAN (IF ANY)

OTHERS PREVIOUS HEALTH

RECORD
DATE DATE
TAKEN RESULT TAKEN RESULT

YSICIAN (IF ANY)

OTHERS PREVIOUS HEALTH
DATE DATE RECORD
RESULT RESULT
TAKEN TAKEN
YSICIAN (IF ANY)
OTHERS PREVIOUS HEALTH
DATE DATE RECORD
RESULT RESULT
TAKEN TAKEN
YSICIAN (IF ANY)
OTHERS PREVIOUS HEALTH
DATE DATE RECORD
RESULT RESULT
TAKEN TAKEN

YSICIAN (IF ANY)

OTHERS PREVIOUS HEALTH
RECORD
 PREVIOUS HEALTH
DATE DATE RECORD
TAKEN RESULT TAKEN RESULT