General Form 86

Republic of the Philippines

Department of Education, Culture and Sports
National Capital Region
DIVISION OF CITY SCHOOLS
Quezon City, 2nd District, Metro Manila

HEALTH EXAMINATION RECORDS

NAME: _______________________________________ DIVISION OF ____________ DEPARTMENT: ____________

DATE OF BIRTH: _______________________________________________ SEX: _______________________________
CIVIL STATUS: ______________________ TITLE OF WORK: _____________________________________________
Date: _____________ Height: ________________
Age: ______________ Weight: ________________

Respiratory System:
____________________________________________________________________________________________________
Fluoroscopy:
____________________________________________________________________________________________________
Sputum Analysis:
____________________________________________________________________________________________________
Circulatory System:
____________________________________________________________________________________________________
Blood Pressure:
Systolic: _________________ Diastolic: ____________________
Digestive System:
____________________________________________________________________________________________________
Genito-urinary System:
____________________________________________________________________________________________________
Urinalysis:
____________________________________________________________________________________________________
Skin:
____________________________________________________________________________________________________
Loco-motor System:
____________________________________________________________________________________________________
Nervous System:
____________________________________________________________________________________________________
Eyes:
____________________________________________________________________________________________________
Color Perception:
____________________________________________________________________________________________________
Vision: Without glasses
With glasses: Far: _________________________ Near: ____________________________________
Ears:

Hearing:
Right ear: _____________________________ Left Ear: __________________________________
Nose:
____________________________________________________________________________________________________
Throat:

Teeth and Gums:

Remarks:
____________________________________________________________________________________________________
Recommendation:
____________________________________________________________________________________________________
Employee’s Signature:
____________________________________________________________________________________________________

Physician’s Signature Over Printed Name: ____________________________

Post Office Address: _______________________________________________
License No.: ______________________________________________________