Republic of the Philippines

DEPARTMENT OF EDUCATION
Region XI
Division of Compostela Valley
Laak North District
______________________________
School

Form No. 86
HEALTH EXAMINATION RECORD

Name : _______________________ Sex : ________ Civil Status: ______________

Date of Birth : _____________________ Type of Work: ___________________
Place of Birth : ____________________ Office : __________________________

1.) Date : _____________ Age: ______ Height: _____ Weight: _____ BMI:____
2.) Respiratory System:
X-ray Film No. : _____________________ Date: _____________
Right Lung : ____________________________________________
Left Lung : ____________________________________________
Mediastrium : ____________________________________________
Impression : ____________________________________________
Recommendation : ____________________________________________
3.) Circulatory System
Blood Pressure : ____________ mmHg
Pulse Rate : _______ Agility Test: After 3 minutes _________
4.) Digestive System : ____________________________________________
5.) Genito-Urinary System : ____________________________________________
6.) Skin : ____________________________________________
7.) Loco-motor System : ____________________________________________
8.) Nervous System : ____________________________________________
9.) Eyes, Conjunctiva, etc. : ____________________________________________
10.) Color Perception : ____________________________________________
11.) Visions: w/ or w/o glasses : ____________________________________________
12.) Ears : ____________________________________________
13.) Throat : ____________________________________________
14.) Nose : ____________________________________________
15.) Teeth : ____________________________________________
16.) Immunization : ____________________________________________

Remarks : _________________________________________________________
Recommendation : _________________________________________________________

Employee's Signature: _________________________

Name and Signature of Physician

Designation

License Number