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    Health Examination Record

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    Lino Anthony Banatao
    This document appears to be a health examination record form containing sections to record a person's personal details, medical history, physical examinations, test results, immunizations, recommendations, and signatures of the employee and examining physician over three examination dates. The form includes fields to document height, weight, vital signs, evaluation of major body systems, vision and hearing tests, and other medical details.

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    Health Examination Record

    Uploaded by

    Lino Anthony Banatao
    43 views1 page
    This document appears to be a health examination record form containing sections to record a person's personal details, medical history, physical examinations, test results, immunizations, recommendations, and signatures of the employee and examining physician over three examination dates. The form includes fields to document height, weight, vital signs, evaluation of major body systems, vision and hearing tests, and other medical details.

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    This document appears to be a health examination record form containing sections to record a person's personal details, medical history, physical examinations, test results, immunizations, recommendations, and signatures of the employee and examining physician over three examination dates. The form includes fields to document height, weight, vital signs, evaluation of major body systems, vision and hearing tests, and other medical details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    43 views1 page

    Health Examination Record

    Uploaded by

    Lino Anthony Banatao
    This document appears to be a health examination record form containing sections to record a person's personal details, medical history, physical examinations, test results, immunizations, recommendations, and signatures of the employee and examining physician over three examination dates. The form includes fields to document height, weight, vital signs, evaluation of major body systems, vision and hearing tests, and other medical details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    CS Form 86

    HEALTH EXAMINATION RECORD


    Name: School: Department:
    Date of Birth: Type of Work: Sex: Civil Status:
    1 Date: Date: Date:
    Height: Weight: Height: Weight: Height: Weight:
    2 Temperature: Temperature: Temperature:
    3 Respiratory System: Respiratory System: Respiratory System:
    Fluorography: Fluorography: Fluorography:
    Sputum Analysis: Sputum Analysis: Sputum Analysis:
    4 Circulatory System: Circulatory System: Circulatory System:
    Blood Pressure: Blood Pressure: Blood Pressure:
    Pulse: Pulse: Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System: Digestive System: Digestive System:
    6 Genito-Urinary: Genito-Urinary: Genito-Urinary:
    Urinalysis, etc: Urinalysis, etc: Urinalysis, etc:
    7 Skin: Skin: Skin:
    8 Locomotor System: Locomotor System: Locomotor System:
    9 Nervous System: Nervous System: Nervous System:
    10 Eyes: Conjunctivitis, etc.: Eyes: Conjunctivitis, etc.: Eyes: Conjunctivitis, etc.:
    Color Perception: Color Perception: Color Perception:
    11 Vision: Vision: Vision:
    With glasses: Far: Near: With glasses: Far: Near: With glasses: Far: Near:
    Without glasses: Far: Near: Without glasses: Far: Near: Without glasses: Far: Near:
    12 Nose: Nose: Nose:
    13 Ear: Ear: Ear:
    14 Hearing: Hearing: Hearing:
    Right: Left: Right: Left: Right: Left:
    15 Throat: Throat: Throat:
    16 Teeth and Gums: Teeth and Gums: Teeth and Gums:
    17 Immunization: Immunization: Immunization:
    18 Remarks: Remarks: Remarks:
    19 Recommendation: Recommendation: Recommendation:
    20 Employee’s Signature: Employee’s Signature: Employee’s Signature:
    Employee’s Name (Print): Employee’s Name (Print): Employee’s Name (Print):
    21 Physician’s Signature: Physician’s Signature: Physician’s Signature:
    Physician’s Name (Print): Physician’s Name (Print): Physician’s Name (Print):

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