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________
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2
3

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:
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7
8
9
10

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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:
Employees Signature
Employees Name (Print)
Physicians Signature

With glasses:
Near:
Without glasses:
Near:

Right:

Far:

With glasses:
Near:
Without glasses:
Near:

Far:

Left:

Right:

Far:
Far:

Left:

Physicians Name (Print)