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General Form No. 86
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HEALTH EXAMINATION FORM
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Name:______________________________
Bureau of Public School, Department of Education
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Date of Birth:________________________
Date:_______________________________________
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1. Date
 Age:Height:
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2. Temperature
Weight:
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3. Respiratory System
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Sputum Analysis
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4. Ciculatory System
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5. Blood Pressure
 Systolic:Diastolic:
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Pulse
 Sitting:
Agility Test:
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 After 3 Min.:
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Blood Analysis
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Digestive System
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6. Genite
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Urinalysis. Etc.
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7. Skin
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8. Loco-motor System
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9. Nervous System
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10. Eye-Conj. Etc.
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11. Calorie Perception
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12. Vision
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Without Glasses
 (Right) Far:Near:
(Right) Far:
Near:
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With Glasses
 (Right) Far:Near:
(Right) Far:
Near:
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13. Ears
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14. Hearing
 Right Ear: Left Ear:
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15. Nose
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16. Throat
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17. Teeth and Gum
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18. Immunization
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Date
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19. Remarks
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20. Recommendation
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21. Employee's Signature _________________________________________________________
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22. Physician's Signature __________________________________________________________
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INSTRUCTION FOR FILING
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1.
Record main activity mad not the official designation
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Example, letter, corner messenger, telephone operator, typist etc.
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2.
Include larynx, bronco and lungs indicate necessity for x-ray and laboratory exanimation when needed and cannot be
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done due to lack of facilities. Record important history and abnormal feelings.
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3.
Include examination for hernia, arms. inflammation of the gall bladder, appendix and assignment of the spleen
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4.
Indicate necessity for laboratory examination when needed and cannot be done due to lack facilities
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5.
Include test for flexibility of joint and reflexes
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6.
Record important History and abnormal findings, test for Arrol Robertson and Member 's sing
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7.
Indicate necessity for special examination if symptoms warrant and no facilities are available
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8.
Use ordinary conversation voice and 6 meters test one ear at a time. Read abnormality as slight, moderate, severe
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or total deafness
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9.
Look especially for diarrhea
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10.
Record other abnormal findings, temporary or permanent, unfitness, for work contagious conditions, etc.
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11.
Record date of immunization against cholera, dysentery and typhoid
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12.
Record is employee needs medical treatment, vacation, separation from service or improvement of certain habits
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13.
Employee must sign in the presence of examining physician
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NOTE: All entries must be written in ink. Any erasure or correction must be signed over by the physician
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