General Form No. 86 HEALTH EXAMINATION FORM
Name:______ Name:____________ ____________ ____________ ___________ _____ Date of Birth: Birth: ___________ _________________ ____________ ______ .Date !"e: $.%emperature '.(e)pirator* S*)tem Sputum !nal*)i) +. irculator* S*). -.Blood Pre))ure Pul)e
Bureau Bureau of Public Public School, School, Department Department of Education Education Date: Date: ___________ _________________ ____________ ____________ ____________ ______ #ei"ht: &ei"ht:
S*)tolic: Sittin": !fter ' min.:
Dia)tolic: !"ilit* %e)t:
9(i"ht Far: 9(i"ht Far:
Near: Near:
Blood !nal*)i) Di"e)tie S*)tem 6. Genite /rinal*)i), etc. 0. S1in 8.2oco3motor )*)tem 4. Nerou) S*)tem 5. E*e3con.,etc . alorie perception $.7i)ion ithout Gla))e) ; "la))e) '. Ear) +. #earin"
(i"ht Ear
92eft Far: 92eft Far: 2eft Ear
Near: Near:
-. No)e 6. %hroat 0. %eeth and Gum 8.
21. Employee’s Employee’s Signature ____________________________________________________________________ ____________________________________________________________________ 22. Physician’s Physician’s Signature ____________________________________________________________________ ____________________________________________________________________ INSTRUCTION FOR FILING
1. 2. %. &. '. ). -. . 0. 1. 11. 12. 1%.
Record Record main main activi activity ty and not the the offici official al designa designation. tion. Example, letter, carrier. messenger, telephone operator, typist etc. nclude larynx, larynx, !ronco and lungs indicate indicate necessity for x"ray and and la!oratory examination #hen #hen needed and cannot !e done done due to lac$ of facilities. Record important history and a!normal feelings. nclude examination examination for for hernia, arms, inflammation inflammation of the gall !ladder, !ladder, appendix and assignment of the spleen. ndicate ndicate necessit necessity y for la!oratory la!oratory examinat examination ion #hen needed needed and cannot cannot !e done due to lac$ faciliti facilities. es. nclude nclude test test for flexi flexi!ili !ility ty of (oint (oint and reflexes. reflexes. Record Record important important *istory *istory and a!norma a!normall findings, findings, test for +rrol +rrol Ro!erts Ro!ertson on and em!er’s em!er’s sing. sing. ndicate ndicate necessit necessity y for special special examination examination if symptom symptomss #arrant #arrant and no facilities facilities are availa! availa!le. le. /se ordinary conversation voice and ) meters test test one ear at a time. time. Read a!normality as slight, moderate, severe severe or total total deafness. oo$ oo$ especi especiall ally y for diarrh diarrhea. ea. Record other a!normal a!normal findings, findings, temporary or permanent, permanent, unfitness, unfitness, for #or$ contagious conditions, conditions, etc. Record date of immuni3ation immuni3ation against against cholera, dysentery and typhoid. Record is employee employee needs medical treatment, treatment, vacation, separation separation from service or improvement improvement of certain ha!its. ha!its. Employee must must sign sign in the the presence presence of examining examining physician. physician.
456E7 +ll entries entries must !e #ritten in in$. in$. +ny +ny erasure or correction correction must !e signed over !y the the physician.
