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    Form 86 New

    Uploaded by

    markegil.carrera
    The document contains health examination records for 5 teachers with information on height, weight, blood pressure, vision, hearing, and physician recommendations. The records are part of an annual health check for teachers in the Tarlac Province Department of Education.

    Copyright:

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

    Form 86 New

    Uploaded by

    markegil.carrera
    11 views9 pages
    The document contains health examination records for 5 teachers with information on height, weight, blood pressure, vision, hearing, and physician recommendations. The records are part of an annual health check for teachers in the Tarlac Province Department of Education.

    Original Description:

    Deped form 86 - health form

    Original Title

    FORM-86-NEW

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    The document contains health examination records for 5 teachers with information on height, weight, blood pressure, vision, hearing, and physician recommendations. The records are part of an annual health check for teachers in the Tarlac Province Department of Education.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    11 views9 pages

    Form 86 New

    Uploaded by

    markegil.carrera
    The document contains health examination records for 5 teachers with information on height, weight, blood pressure, vision, hearing, and physician recommendations. The records are part of an annual health check for teachers in the Tarlac Province Department of Education.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 9

    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: MARIA GRACIELA D. PASUQUIN Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: DECEMBER 29, 1978 Type of Work: TEACHING Sex: FEMALE Civil Status: MARRIED

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)
    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: LORETO C. MORALES Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: AUGUST 18, 1990 Type of Work: TEACHING Sex: MALE Civil Status: SINGLE

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)
    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: MARINEL L. PASCUA Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: FEBRUARY 02, 1988 Type of Work: TEACHING Sex: FEMALE Civil Status: SINGLE

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)
    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: GLAIZA L. CASTRO Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: SEPTEMBER 24, 1985 Type of Work: TEACHING Sex: FEMALE Civil Status: MARRIED

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)
    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: LORENA B. LIMBANIA Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: AUGUST 07, 1988 Type of Work: TEACHING Sex: FEMALE Civil Status: SINGLE

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)
    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: ROSEMARIE L. GALAPON Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: OCTOBER 21, 1986 Type of Work: TEACHING Sex: FEMALE Civil Status: MARRIED

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)
    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: CYNTHIA L. SANTOS Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: MARCH 14, 1994 Type of Work: TEACHING Sex: FEMALE Civil Status: MARRIED

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)
    CS FORM 86

    HEALTH EXAMINATION RECORD


    Name: EDWARD M. CAYABYAB Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION

    Date of Birth: MAY 21, 1970 Type of Work: TEACHING Sex: MALE Civil Status: MARRIED

    Date: Date: Date:


    1 Height Height Height
    Weight Weight Weight
    2 Temperature:
    Respiratory System:
    3 Fluorography:
    Sputum Analysis:
    Circulatory System:
    Blood Pressure:
    4
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    Genito-Urinary:
    6
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    Eyes: Conjunctivitis, etc.:
    10
    Color Perception:
    Vision:
    11 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:
    13 Ear:
    Hearing:
    14
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation:
    Employee’s Signature
    20
    Employee’s Name (Print)
    Physician’s Signature
    21
    Physician’s Name (Print)

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