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Cs Form 86 - Health Examination Record
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Cs Form 86 - Health Examination Record
Cs Form 86 - Health Examination RecordFull description...
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Edmon-Ivy Lynn Sosing-Giray Tan
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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)
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