FORM-86-NEW.doc
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This document contains a health examination record for a civil servant. It includes sections to record personal details like name, date of birth, type of work, and civil status. It also includes sections to record measurements of height, weight, temperature, and assessments of various body systems like respiratory, circulatory, digestive, genitourinary, skin, locomotor, nervous, eyes, ears, nose, throat, teeth and gums. There are also sections to record vision testing results, hearing tests, immunization history, any remarks, physician recommendations, and signatures of the employee and examining physician.
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FORM-86-NEW.doc
- 1. CS FORM 86 HEALTH EXAMINATION RECORD Name: ____________ Division: TARLAC PROVINCE Department: DEPARTMENT OF EDUCATION__ Date of Birth: Type of Work: Sex: Civil Status: . 1 Date: Date: Date: Height Height Height Weight Weight Weight 2 Temperature: 3 Respiratory System: Fluorography: Sputum Analysis: 4 Circulatory System: Blood Pressure: Pulse: Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test: 5 Digestive System: 6 Genito-Urinary: Urinalysis, etc.: 7 Skin: 8 Locomotor System: 9 Nervous System: 10 Eyes: Conjunctivitis, etc.: Color Perception: 11 Vision: With glasses: Far: Near: With glasses: Far: Near: With glasses: Far: Near: Without glasses: Far: Near: Without glasses: Far: Near: Without glasses: Far: Near: 12 Nose: 13 Ear: 14 Hearing: Right: Left: Right: Left: Right: Left: 15 Throat: 16 Teeth and Gums: 17 Immunization: 18 Remarks: 19 Recommendation: 20 Employee’s Signature Employee’s Name (Print) 21 Physician’s Signature Physician’s Name (Print)