Republic of the Philippines

Department of Education
Region 02
Schools Division Office of Cagayan
Lingu, Solana, Cagayan

Enclosure to Div. Memo No. 6, s. 1967

General Form 86

HEALTH EXAMINATION RECORD

NAME: MARITES C. RIVERA Department: Department of Education
Date of Birth: 05/05/1980 Sex: FEMALE
Civil Status M Type of Work: TEACHING

1. Date: _____________ Date: ______________Height: ______cm. Date: _____________Weight: ______ kg.

2. __________________ Age: ______________Weight: ______kg Age: _____________ Height: ______cm.
Temperature: ___________________________________________________________________________
3. Respiratory System: ( ) Symmetrical Chest Expansion ( ) Clear Breath Sounds
4. Sputum Analysis: _____________________________________________________________________
5. Circulatory System: ( ) Normal rate ( ) Regular rhythm ( ) murmur
Blood Pressure Systolic: __________ Diastolic: ____________ Sys. ________ Dias. ____________
Pulse: __________ Sitting: ____________ Agility: ___________________________________________
6. Digestive System: ( ) Normo-active bowel sounds
7. Genito-Urinary: ( ) Unremarkale ( ) Remarkable
8. Skin: ( ) Rashes ( ) Good skin turgor
9. Locomotor system: ( ) Deformity ( ) Full range of motion
10. Nervous System: ( ) Oriented to 3 spheres
11. Eyes, Conjunction, etc.: ( ) anicteric sclerae ( ) pale palpebral conjunctivae
12. Color Perception: ( ) Normal
13. Vision: Without glasses Far: ________ Near: ___________ Far: ___________ Near: _________
With glasses Far: ________ Near: ___________ Far: __________ Near: _________
14. Ears: ( ) Unremarkable ( ) Remarkable
15. Hearing: Right Ear: ____________________________ Right Ear: _____________________________
Left Ear: ____________________________ Left Ear: _____________________________
16. Nose: ( ) Nasal septum midline
17. Throat: ( ) Cervical lymph adenopathy
18. Teeth and Gums: ( ) Healthy
19. Immunization: __________________________________________________________________________
Date: _________________________________________________________________________________
20. Recommendations: ______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Employee’s Signature: _______________________________________

Physician’s Signature: _______________________________________

Note: Please submit yourself to a government physician for the above check-up and not to a private practitioner.