General Form 86

HEALTH EXAMINATION RECORD

Name: _________________________________________School: DepEd-__________________________

Date of Birth: _____________________ Sex: ________ Age: __________ Civil Status: ______________

Date examined: ____________________ Height: _______cm Weight: ______ kg BMI _____________

Type of Work: ______________________________________ Temp: _________PR: __________bpm

Respiratory System: _____________________________________________________________________

Circulatory System: _____________________________________________________________________
Blood Pressure: ___________PR:_______ Systolic:________ Diastolic:________ O2 sat_____%
Pulse Setting: __________________________ Agility Test: ___________After 3 mins:______
Digestive System: _______________________________________________________________________
Genito-Urinary System: __________________________________________________________________
Urinalysis, etc: ___________________________________________________________________
Skin: _________________________________________________________________________________
Loco-Motor System: ____________________________________________________________________
Nervous System: _______________________________________________________________________
Eyes: Conjunctiva: etc: __________________________________________________________________
Color Perception: _______________________________________________________________________
VISION Without glasses Far: ________________________ Near: _______________________
With glasses Far: ________________________ Near: _______________________
Ears: __________________________________________________________________________________
Hearing: _____________________ Right Ear: ___________________ Left Ear: ___________________
Nose: _________________________________________________________________________________
Throat: _______________________________________________________________________________
Teeth and Gum: ________________________________________________________________________
Immunization and Date: _____________________________________ FBS: _______________________
Fluoroscopy: ___________________________________________________________________________

Recommendation: _______________________________________________________________________

Employee’s Signature: ________________________

___________________________
(Physician)
Signature over Printed Name
License Number:____________