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Letter For Leave

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Republic of the Philippines

Department of Education
Region V - Bicol
SCHOOLS DIVISION OFFICE OF ALBAY
ALONGONG ELEMENTARY SCHOOL
ALONGONG, LIBON, ALBAY

Name: JENETH R, ARMILLO District: _LIBON WEST_ School: HARIGUE ELEMENTARY


Address: HARIGUE LIBON ALBAY Type of Work: TEACHER
Age: 32 Sex: FEMALE Civil Status: MARRIED Weight: ___ Height: __

1. Respiratory System ____________ Date: ____________


____________________________ 8. Eyes ____________________________
Fluoroscopy _________________ _____________________________
Right Lung __________________ Color Perception______________________
Left Lung ___________________ Vision Test__________________________
Temperature _________________ BV R ____________________________
N L____________________________
2. Circulatory System ____________ NV R_____________________________
____________________________ L ____________________________
Blood Pressure _______________ 9. Ears______________________________
Systolic___________ Hearing __________________________
Diastolic _________ Tickling of Water ___________________
Pulse Conversation ______________________
Sitting ______ ________________________
Agility _____
10. Nose ____________________________
Digestive System______________
11. Throat ___________________________
3. Urinalysis 12. Teeth ___________________________
Color ______ Sp. Gravity______ 13. Immunization _____________________
Sugar ______ Albumin________ ______________________________
Blood ______ Casts __________
Pus ________ Others _________ 14. Remarks __________________________
________________________________
4. Skin _____________________________ 15. Recommendation
_________________________________ _______________________________
________________________________
5. Nervous System: ___________________ _______________________________
_________________________________

6. Cardiovascular System ______________


_________________________________

7. Other Findings ____________________


_________________________________
_________________________________
Thumbmark
Purpose: _________________________
__________________________________
__________________________________

______________________________________

Lic. No._______________________________

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