General Form 86

DepEd- SDO, Surigao City

HEALTH EXAMINATION RECORD

Name: _________________________________________ Contact No:____________________

School: ______________________________ District_____ Designation/Position:____________
Date of Birth:_________________________ Sex: ____ Age: _______ Civil Status: _______

Date examined: ____________________ Height: _______ Weight: ________ BMI __________

Respiratory System: ______________________________________________________________
Circulatory System: ______________________________________________________________
Blood Type: ________________
Blood Pressure: _____________ 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: _________________________________________________________________

Type of Covid Vaccine__________________ 1st Dose Date____________2nd dose date___________

Booster Dose Vaccine/ Date____________________________________ FBS: _______________
Fluoroscopy: ____________________________________________________________________

Findings & Recommendation: ______________________________________________________

Employee’s Signature: _____________________

___________________________________
Physician’s Signature over Printed Name
License Number: ____________