15. Hearing, 17. Teeth: & Guas, SORM @& 5 : HEALTH EXAMINATION Name: = Date of Birtbr i> en z * Civil’ Status: SITE" Type of Works. 1. Dates weight Heights Weight Weignt: = =) Jaereystures » lespiretory Eyster 2 + etulniory System 2 __ eed Preszure, 2Systolic Diastolic. sGystolac, Diastolic oe Agility Test. Sitting Agility Test . sAfter 3 ain walysis, z ss : - ave System 2 : = 6 vito-urinary, > a __ Urinalysis, ete. ‘7. Skin, 8. Locondtor System. 9. Nervous System. 10. Eyes, Conjunctive et 12 toler Perception 2. Vision w/o glasses: Wolasses. 3. Ears. . Nose, 4. Throat, 18. Immunization ‘ Date. ‘ 19. Remarks, z t 20. RECORMENDATION, E i 1 messenger. telephone onerator, typist, executive, etc. 2 hi A 1. Eaployes’s Siapature: Physician's Signature “OTMSTRUCTION FOR FILING + Record ‘main activity and not the official designation. Example letter carrier, , Include larynx, bronche and lungs. Indicate necessity for X-ray and laboratory ‘hens when needed and: cannot he denetdue to Tack of facilities. Hecord isoortant nd abnormal findings. , -iude test for recuperative power, of the heart and blood pressure. i-t0ry and abnoraal, findings. * = Include examination for. hernia, anus, inflasstion of the gall blader, appendix and “enlargement of the spleen. 5. Rea aoc sade ceat Aa sors anne tary ates ne eeh chan herea eva fecamet oe aoe ore lack of facilities. Record important history and abnoraal tindine, when exarination 2s not done for reason of sex record not examined. 6 - Include test for flexidility of joints and reflexes. | + Record imvortast hestory and ahnorsal findings. | Test for Argyll Horertsrn ano Romberg’s signs. a + Ingicete necessity for specialist examination if symptom warrant and do facilities ere availabje. 9. al 19., hook especially for pyerrhe 1 . Use ordinary conversational voice at 6 seters. Jest one ear at a time. ecord bnormality 9s siight, zoderate; severe or total deztness. 1. Record date of immunization ‘against cholera, oysentery and typhoin. ‘12. Record other atnormal findinas, ternorary or permanenthuntitness for work, contacic.< conditions, ete. 13, 3. Record if employee needs, medical treatment, vacation, separation from service oF aprovement of certain habits. + 34. Fandeyee mist sign in the presence of examining physicians. : NOTE: ALL entries must be written in ink. ny erasure or correction must he signed by the ‘physicien: