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    Health Examination Form: Instruction For Filing

    Uploaded by

    Jonathan
    The document appears to be a health examination form for employees of the Bureau of Public Schools Department of Education. It contains sections to record identifying information of the employee, medical measurements and tests of various body systems and functions, vision tests, immunization history, physician recommendations, and signatures of the employee and examining physician. Instructions at the bottom specify how to complete the form, including writing in ink and signing corrections.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Health Examination Form: Instruction For Filing

    Uploaded by

    Jonathan
    33 views3 pages
    The document appears to be a health examination form for employees of the Bureau of Public Schools Department of Education. It contains sections to record identifying information of the employee, medical measurements and tests of various body systems and functions, vision tests, immunization history, physician recommendations, and signatures of the employee and examining physician. Instructions at the bottom specify how to complete the form, including writing in ink and signing corrections.

    Original Description:

    Original Title

    General-Form-86

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    The document appears to be a health examination form for employees of the Bureau of Public Schools Department of Education. It contains sections to record identifying information of the employee, medical measurements and tests of various body systems and functions, vision tests, immunization history, physician recommendations, and signatures of the employee and examining physician. Instructions at the bottom specify how to complete the form, including writing in ink and signing corrections.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    33 views3 pages

    Health Examination Form: Instruction For Filing

    Uploaded by

    Jonathan
    The document appears to be a health examination form for employees of the Bureau of Public Schools Department of Education. It contains sections to record identifying information of the employee, medical measurements and tests of various body systems and functions, vision tests, immunization history, physician recommendations, and signatures of the employee and examining physician. Instructions at the bottom specify how to complete the form, including writing in ink and signing corrections.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    General Form 86

    HEALTH EXAMINATION FORM

    Name: JONATHAN L. MADALIPAY Bureau of Public School, Department of


    Education
    Date of Birth: MAY 10, 1989 Date: _____________________

    1.Date: Age Height:


    2. Temperature Weight:
    3. Respiratory System
    Sputum Analysis
    4. Circulatory Sys
    5. Blood Pressure Systolic: Diastolic:
    Pulse: Sitting: Agility Test:
    Blood Analysis
    Digestive System
    6. Genite
    Urinalysis, etc.
    7. Skin
    8. Loco-Motor System
    9. Nervous System
    10. Eye-Conj. Etc.
    11. Calorie Perception
    12. Vision without
    Glasses (Right) Far: Near: (Left) Far: Near:
    w/ glasses (Right) Far: Near: (Left) Far: Near:
    13. Ears
    14. Hearing Right Ear Left Ear:
    15. Nose
    16. Throat
    17. Teeth and Gum
    18. Immunization
    Date
    19. Remarks

    20. Recommendation

    21. Employee’s Signature: _________________________________________

    22. Physicians signature: __________________________________________

    INSTRUCTION FOR FILING

    1. Record the main activity and not official designation.


    Example: Letter, Carrier, Messenger, Telephone Operator, Typist, etc.
    2. Include Larynx, Bronco and lungs indicate necessity for x-ray and laboratory examination when needed and cannot be
    done due to lack of facilities. Record important history and abnormal findings.
    3. Include Examination to Hernia, arms, inflammation of the gallbladder, appendix and assignment of the spleen.
    4.Indicate necessity for laboratory due to lack of facilities.
    5. Include test for flexibility of joint and reflexes.
    6. Record important and abnormal findings, Test for Arrol Robertson and member’s sing.
    7. Indicate necessity for special examination if symptoms warrant and no facilities are available.
    8. Use ordinary conversation voice and 6 meters test one ear at a time. Read abnormality as sight, moderate, severe or
    total deafness.
    9. Look especially for Diarhea
    10. Record other abnormal findings, temporary of permanent, unfitness, for work contagious condition, etc.
    11. Record date of immunization against cholera, dysentery and typhoid.
    12. Record if employee needs medical treatment, vacation, separation from service or improvement of certain habits .
    13. Employee must sign in the presence of examining Physician.
    Note: All entries must be written in ink. Any correction must be signed over by the Physician.
    General Form 86

    HEALTH EXAMINATION FORM

    Name: DR. ELBA B. BACINILLO Bureau of Public School, Department of Education


    Date of Birth: ________________________ Date: _____________________

    1.Date: Age Height:


    2. Temperature Weight:
    3. Respiratory System
    Sputum Analysis
    4. Circulatory Sys
    5. Blood Pressure Systolic: Diastolic:
    Pulse: Sitting: Agility Test:
    Blood Analysis
    Digestive System
    6. Genite
    Urinalysis, etc.
    7. Skin
    8. Loco-Motor System
    9. Nervous System
    10. Eye-Conj. Etc.
    11. Calorie Perception
    12. Vision without
    Glasses (Right) Far: Near: (Left) Far: Near:
    w/ glasses (Right) Far: Near: (Left) Far: Near:
    13. Ears
    14. Hearing Right Ear Left Ear:
    15. Nose
    16. Throat
    17. Teeth and Gum
    18. Immunization
    Date
    19. Remarks

    20. Recommendation

    21. Employee’s Signature: _________________________________________

    22. Physicians signature: __________________________________________

    INSTRUCTION FOR FILING

    1. Record the main activity and not official designation.


    Example: Letter, Carrier, Messenger, Telephone Operator, Typist, etc.
    2. Include Larynx, Bronco and lungs indicate necessity for x-ray and laboratory examination when needed and cannot be
    done due to lack of facilities. Record important history and abnormal findings.
    3. Include Examination to Hernia, arms, inflammation of the gallbladder, appendix and assignment of the spleen.
    4.Indicate necessity for laboratory due to lack of facilities.
    5. Include test for flexibility of joint and reflexes.
    6. Record important and abnormal findings, Test for Arrol Robertson and member’s sing.
    7. Indicate necessity for special examination if symptoms warrant and no facilities are available.
    8. Use ordinary conversation voice and 6 meters test one ear at a time. Read abnormality as sight, moderate, severe or
    total deafness.
    9. Look especially for Diarhea
    10. Record other abnormal findings, temporary of permanent, unfitness, for work contagious condition, etc.
    11. Record date of immunization against cholera, dysentery and typhoid.
    12. Record if employee needs medical treatment, vacation, separation from service or improvement of certain habits .
    13. Employee must sign in the presence of examining Physician.
    Note: All entries must be written in ink. Any correction must be signed over by the Physician.

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