Cs Form 86 - Health Examination Record

HEALTH EXAMINATION RECORD

CS FORM 86

Name: SHERWIN P. AMORES Department: DEPARTMENT OF EDUCATION_______

Division: PAGADIAN CITY

Date of Birth: MARCH 24, 1981 Sex: MALE Civil Status: MARRIED________ 1 2 3

4

Date: Height Weight Temperature: Respiratory System: Fluorography: Sputum Analysis: Circulatory System: Blood Pressure: Pulse: Sitting:

Type of Work: TEACHING

Date: Height Weight

Agility Test:

Date: Height Weight

Sitting:

Agility Test:

Sitting:

Agility

Test: 5 6 7 8 9 10

11 12 13 14 15 16 17 18 19 20 21

Digestive System: Genito-Urinary: Urinalysis, etc.: Skin: Locomotor System: Nervous System: Eyes: Conjunctivitis, etc.: Color Perception: Vision: With glasses: Far: Near: Without glasses: Far: Near: Nose: Ear: Hearing: Right: Left: Throat: Teeth and Gums: Immunization: Remarks: Recommendation: Employee’s Signature Employee’s Name (Print) Physician’s Signature

With glasses: Near: Without glasses: Near:

Right:

Far:

With glasses: Near: Without glasses: Near:

Far:

Left:

Right:

Far: Far:

Left:

Physician’s Name (Print)