REVISED FORM 86

Department of Education
HEALTH AND NUTRITION CENTER

Name: GERALD V. LAUGLAUG Region: SOCCSKSARGEN Division: SARANGANI

GLAN-PADIDU, GLAN
Date of Birth: SEPTEMBER 26, 1988 SARANGANI PROVINCECivil Status: MARRIED
Place of Birth:
TANGAN INTEGRATED SCHOOL MALE
TEACHER
School: Occupation: Sex:
33

Age: Wt: Height: 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

Chest X-ray:
Urinalysis:
Fecalysis:
Other Lab Exams:

DIAGNOSIS:

TREATMENT:

REMARKS:

GERALD V. LAUGLAUG
Employee’s Signature (over printed name)
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