General Form No.

86
HEALTH EXAMINATION FORM
Name:_____________________________ Bureau of Public School, Department of Education
Date of Birth: _______________________ Date: ___________________________________
1.Date Age: Height:
2.Temperature Weight:
3.Respiratory System
Sputum Analysis
4. Circulatory Sys.

5.Blood Pressure Systolic: Diastolic:

Pulse Sitting: Agility Test:
After 3 min.:
Blood Analysis
Digestive System
6. Genite

Urinalysis, etc.

7. Skin

8.Loco-motor system

9. Nervous System

10. Eye-conj.,etc

11. Calorie perception

12.Vision without
Glasses (Right) Far: Near: (Left) Far: Near:
w/ glasses (Right) Far: Near: (Left) Far: Near:
13. Ears
14. Hearing Right Ear Left Ear

15. Nose

16. Throat

17. Teeth and Gum

18. Immunization
Date
19. Remarks

20. Recommendation

21. Employee’s Signature ____________________________________________________________________

22. Physician’s Signature ____________________________________________________________________

INSTRUCTION FOR FILING
1. Record main activity and not the official designation.
Example, letter, carrier. messenger, telephone operator, typist etc.
2. Include larynx, bronco and lungs indicate necessity for x-ray and laboratory examination when needed and cannot be done due to
lack of facilities. Record important history and abnormal feelings.
3. Include examination for hernia, arms, inflammation of the gall bladder, appendix and assignment of the spleen.
4. Indicate necessity for laboratory examination when needed and cannot be done due to lack facilities.
5. Include test for flexibility of joint and reflexes.
6. Record important History and abnormal findings, test for Arrol Robertson and Member’s sing.
7. Indicate necessity for special examination if symptoms warrant and no facilities are available.
8. Use ordinary conversation voice and 6 meters test one ear at a time. Read abnormality as slight, moderate, severe or total
deafness.
9. Look especially for diarrhea.
10. Record other abnormal findings, temporary or permanent, unfitness, for work contagious conditions, etc.
11. Record date of immunization against cholera, dysentery and typhoid.
12. Record is employee needs medical treatment, vacation, separation from service or improvement of certain habits.
13. Employee must sign in the presence of examining physician.

NOTE: All entries must be written in ink. Any erasure or correction must be signed over by the physician.