General Form No.

86

HEALTH EXAMINATION FORM

Name: ____________________________________________________ Bureau of Public School, Department of Education

Date of Birth: Date:

1. Date: Age: Height:

2.Temperature Weight:
3. Respiratory System
Sputum Analysis
4. Circulatory Sys.
5. Blood Pressure Systolic: Diastolic:
Pulse: Sitting: Agility test:
Blood Analysis
Digestive System
6.Genite
Urinalysis, etc.
7. Skin
8. Loco-Motor System
9. Nervous System
10. Eye-Conj. Etc.
11. Calorie Perception
12. Vision without
Glasses (Right) Far: Near: (Left)Far: Near:
w/ Glasses (Right) Far: Near: (Left)Far: Near:
13. Ears
14. Hearing Right Ear: Left Ear:
15. Nose
16. Throat
17. Teeth and Gum
18. Immunization
Date
19. Remarks

20. Recommendation

21. Emloyee's Signature _________________________________________________________________

22. Physicians Signature: _________________________________________________________________

INSTRUCTION FOR FILLING

1. Record main activity and not official designation

Example: Letter.Carrier, Messenger,Telephone Opeartor,Typist etc.
2. Include Larynx,Broncho and lungs indicate necessity for x-ray and laboratory examinationwhen needed and cannot be done
due to lack of facilities.Record important history and abnormal findings
3. Include Examination to Hernia , arms, inflammation of the gallbladder,appendix and assignment of the spleen.
4. Indivate necessity for Laboratory examination due to lack of facilities
5. Include test for flexibility of joint and reflexes
6. Record important history and abnormal findings, Test for Arrol Robertson and member's sing.
7. Indicate necessity for special examination if symptoms warrant and no facilities are available
8. Use ordinary conversation voice and 6 meters test one ear at a time.Read abnormality as slight, moderate,severe or total
deafness
9. Look especially for Diarrhea
10. Record other abnormal findings, temporary or permanent, unfitness, for work contagious condition, etc.
11. Record date of immunization against cholera,dysentery and typhoid.
12. Record if employee needs medical treatment,vacation,separation from service or improvement of certain habits
13. Employee must sign in the presence of examining Physician

NOTE: All enttries muat be written in ink. Any correction must be signed over by the physician.