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Form 86

H E A L T H E X A M I N A T I O N R E C O R D
Name: MABETH T. TOYOGON Division: GENERAL SANTOS CITY Department of Education
Date of Birth: AUGUST 31, 1978 Type of Work: TEACHING Sex: FEMALE Civil Status: SINGLE
1 Date: Date: Date:
Height: Height: Height:
Weight: Weight: Weight:
2 Temperature Temperature Temperature
3 Respiratory System: Respiratory System: Respiratory System:
Fluoroscopy: Fluoroscopy: Fluoroscopy:
Sputum Analysis: Sputum Analysis: Sputum Analysis:
4 Circulatory System Circulatory System Circulatory System
Blood Pressure: Blood Pressure: Blood Pressure:
Pulse: Pulse: Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System: Digestive System: Digestive System:
6 Genito-Urinary: Genito-Urinary: Genito-Urinary:
Urinalysis, etc.: Urinalysis, etc.: Urinalysis, etc.:
7 Skin Skin Skin
8 Locomotor System Locomotor System Locomotor System
9 Nervous System Nervous System Nervous System
1 Eyes: Conjunctivitis, etc. Eyes: Conjunctivitis, etc. Eyes: Conjunctivitis, etc.
0 Color Perception: Color Perception: Color Perception:
1 Vision Vision Vision
1 With glasses: Far:______ Near: ______ With glasses: Far:______ Near: ______ With glasses: Far:______ Near: ______
W/o glasses: Far:______ Near: ______ W/o glasses: Far:______ Near: ______ W/o glasses: Far:______ Near: ______
1 Nose Nose Nose
2
1 Ear: Ear: Ear:
3
1 Hearing: Hearing: Hearing:
4 Right: Left: Right: Left: Right: Left:
1 Throat: Throat: Throat:
5
1 Teeth and Gums: Teeth and Gums: Teeth and Gums:
6
1 Immunization: Immunization: Immunization:
7
1 Remarks: Remarks: Remarks:
8
1 Recommendation: Recommendation: Recommendation:
9
2 Employee’s Signature: Employee’s Signature: Employee’s Signature:
0 Employee’s Name (Print): Employee’s Name (Print): Employee’s Name (Print):
2 Physician’s Signature: Physician’s Signature: Physician’s Signature:
1 Physician’s Name (Print): Physician’s Name (Print): Physician’s Name (Print):

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