Form no.

86
Republic of the Philippines
Department of Education
Region IV-A (CALABARZON)
Division of Quezon
Pagbilao, Quezon

PHYSICAL AND MEDICAL HEALTH RECORD

Date: __________________ School: __________________________ District: _______________

Name: ____________________________________________________ Sex: __________________
Age: ______________________ Race: _____________________________________________
Civil Status: ________________ Birth Place: ________________________________________
Address: __________________________________________________________________________

1. Vital Signs: 12. Circulatory System:

Weight _______ Height _______ Pulse Sitting: __________________
Temp. ________ BP __________ Agility Test: __________________
PR ___________ RR _________ After 2 minutes:________________
2. Eyes:
13. Digestive System:
____________________________
_____________________________
____________________________
_____________________________
3. Color perception
14. Genito-Urinary
____________________________
_____________________________
_____________________________
4. Vision:
15. Skin:
V.A. OD: ____________________
_____________________________
OS: ____________________
_____________________________
Near AD: ____________________
16. Back and Spine:
5. Ears:
_____________________________
____________________________
_____________________________

6. Hearing:
17. Extremities:
Ordinary conversation
_____________________________
AD: _______ ft. AS: ________ ft.
_____________________________

7. Nose:
18. Nervous System:
____________________________
_____________________________
_____________________________
8. Mouth:
____________________________
19. Immunization:
_____________________________
9. Throat:
_____________________________
____________________________

20. Remarks:
10. Neck:
_____________________________
____________________________
_____________________________
____________________________

21. Recommendation:
11. Respiratory System:
_____________________________
____________________________
_____________________________
____________________________
Chest X-Ray
_________________________ MD.
No. ________ Date: __________
Medical Examiner
PL ________________________
_________________________
LL ________________________
Date
_________________________
Signature of Patient