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FORM 86.

5
Republic of the Philippines
Department of Education
Region 2
Division of Cagayan
LEMU NATIONAL HIGH SCHOOL
LEMU, ENRILE, CAGAYAN

MEDICAL CLEARANCE FORM

Name: _______________________________ Region: _______ Division: ____________________

Date of Birth: _________________________ Place of Birth: _______________________________

Civil Status: _______________________ Occupation: _______________________ Sex: _________

Date of Examination: _____________________ Age: _____________ Height: _________________

Weight: ________ Temperature: ________________ Bp: ____________ PR: _________________

PAST HISTORY: ____________________________________________________________________

PHYSICAL EXAMINATION:

SKIN:

___________________________________________________________________________________

EENT: ______________________________________________________________________________

CHEST/LUNGS: _______________________________________________________________________

HEART: ______________________________________________________________________________

ABDOMEN: __________________________________________________________________________

EXTREMITIES: ________________________________________________________________________

GUT: ______________________________________________________________________________

CNS: ______________________________________________________________________________

LABORATORY EXAMINATION: __________________________________________________________

CHEST X RAY:
___________________________________________________________________________________

DIAGNOSIS:
___________________________________________________________________________________

TREATMENT: _________________________________________________________________________

REMARKS: ___________________________________________________________________________

EMPLOYEE’S SIGNATURE: ________________________________________________________________

PHYSICIAN’S SIGNATURE: ________________________________________________________________

DESIGNATION: ________________________________________________________________________

PTR. LICENSE NO.: ______________________________________________________________________


FORM 86.5
Republic of the Philippines
Department of Education
Region 2
Division of Cagayan
LEMU NATIONAL HIGH SCHOOL
LEMU, ENRILE, CAGAYAN

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