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  • Form 86 - Health Form

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    This document contains a health examination record for an employee. It includes sections to record information about the employee's respiratory, circulatory, digestive, genito-urinary, skin, locomotor, nervous, eyes/vision, ears, throat, nose, teeth, and immunization status. The form also includes spaces for remarks and recommendations by the examining physician.

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    This document contains a health examination record for an employee. It includes sections to record information about the employee's respiratory, circulatory, digestive, genito-urinary, skin, locomotor, nervous, eyes/vision, ears, throat, nose, teeth, and immunization status. The form also includes spaces for remarks and recommendations by the examining physician.

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    283 Ansichten1 Seite

    Form 86 - Health Form

    Hochgeladen von

    bogtik
    This document contains a health examination record for an employee. It includes sections to record information about the employee's respiratory, circulatory, digestive, genito-urinary, skin, locomotor, nervous, eyes/vision, ears, throat, nose, teeth, and immunization status. The form also includes spaces for remarks and recommendations by the examining physician.

    Copyright:

    © All Rights Reserved
    Als DOCX, PDF, TXT herunterladen oder online auf Scribd lesen
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    von 1

    General Form No.

    86
    Republika ng Pilipinas
    Kagawaran ng Edukasyon
    REHIYON XI
    Sangay ng Davao del Norte
    Tagum City

    HEALTH EXAMINATION RECORD

    Name: ________________________________ Sex: _____ Civil Status:__________


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

    1. Date:______________ Age:______ Height:________ BMI: ___________


    2. Respiratory System: _________________________________________________________
    Flourography Film No.____________________ Date:_____________________
    Right Lung. . . . . . . . . ______________________________________________
    Left Lung . . . . . . . . . .______________________________________________
    Mediastinum. . . . . . . _______________________________________________
    Impression. . . . . . . . ________________________________________________
    Recommendation. . . _______________________________________________
    3. Circulatory System:__________________________________________________________
    Blood Pressure. . . . .Systolic:_________mmHg Diastolic:___________mmHg
    Pulse Rate. . . . . .Sitting:________Agility Test: After 3mins._____________
    4. Digestive System:___________________________________________________________
    5. Genito-urinary System:_______________________________________________________
    6. Skin:_____________________________________________________________________
    7. Loco-motor System:_________________________________________________________
    8. Nervous System:____________________________________________________________
    9. Eyes, Conjunctiva etc.:_______________________________________________________
    10. Color Perception:___________________________________________________________
    11. Vision: with/ without glasses:_________________________________________________
    12. Ears:_____________________________________________________________________
    13. Throat:___________________________________________________________________
    14. Nose:____________________________________________________________________
    15. Teeth:___________________________________________________________________
    16. Immunization:_____________________________________________________________

    Remarks:____________________________________________________________________
    Recommendation:_____________________________________________________________
    _____________________________________________________________

    Employee’s Signature:__________________

    EARL R. CANASTILLO, MD.


    Medical Officer IV
    License No. 006552

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