form 86

Republic of the Philippines Department of Education National Capital Region

DIVISION OF MARIKINA CITY

HEALTH EXAMINATION RECORDSHEALTH EXAMINATION RECORDSHEALTH EXAMINATION RECORDSHEALTH EXAMINATION RECORDS

NAME: _______________________________________ SCHOOL: _______________________ DATE OF BIRTH: ______________________________ SEX: ___________ AGE: __________ CIVIL STATUS: ________________________________ TITLE OF WORK : ________________ 1 Date: Height: Weight: 2 Temperature 3 Respiratory 4 Flouroscopy 5 Blood Pressure 6 Pulse 7 Digestive System 8 Genito-Urinary 9 Skin 10 Loco-motor System 11 Nervous system 12 Eyes, Conjunctiva, etc. 13 Color Perception 14 Vision w/o glasses w/ glasses 15 Ears Rt. Ear: Left Ear: 16 Hearing 17 Nose 18 Throat 19 Teeth & Gum 20 Immunization Date of Immunization 21 Remarks

22 Recommendation

23 Employee’s Signature

24 Physician’s Signature

All entries must be written in ink. Any erasure or correction must be signed by the physician.