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Form 86

This document contains a health examination record for a teacher. It collects information about the teacher's family history, past medical history, social history, and present health status through a series of checkboxes. Examination results are also documented, including tests of the cardiovascular, respiratory, and other body systems. The form is used to document the teacher's health and make recommendations.

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Hanna Jane Bayarcal
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93 views

Form 86

This document contains a health examination record for a teacher. It collects information about the teacher's family history, past medical history, social history, and present health status through a series of checkboxes. Examination results are also documented, including tests of the cardiovascular, respiratory, and other body systems. The form is used to document the teacher's health and make recommendations.

Uploaded by

Hanna Jane Bayarcal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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HEALTH EXAMINATION RECO

Name: Division:
Date of Birth: Type of Work:

1 Date: Date:
Height Height
Weight Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: __________ Near: _________ With glasses: Far: __________
Without glasses: Far: __________ Near: _________ Without glasses: Far: __________
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee's Signature:
Employee's Name (Print):
21 Physician's Signature:
Physician's Name (Print):
AMINATION RECORD
Department:
Sex: Civil Status:

Date:
Height
Weight

Agility Test: Sitting: Agility Test:

Far: __________ Near: _________ With glasses: Far: __________ Near: _________
Far: __________ Near: _________ Without glasses: Far: __________ Near: _________

Right: Left:
TEACHER'S HEALTH CARD
Date:
Name: Date of Birth: Age: Gender:
School/District/Division: Civil Status
Position/Designation: Years in Service:
First Year in Service:

Family History: (pls. check) Y N Specify Relationship


Hypertension [ ] [ ]
Cardiovascular Disease [ ] [ ]
Diabetes Mellitus [ ] [ ]
Kidney Disease [ ] [ ]
Cancer [ ] [ ]
Asthma [ ] [ ]
Allergy [ ] [ ]
Other Remarks:

Past Medical History: (check)


Y N
Hypertension [ ] [ ] Tuberculosis
Asthma [ ] [ ] Surgical Operations (pls. specify)
Diabetes Mellitus [ ] [ ] Yellowish discoloration of skin/sclera
Cardiovascular Disease [ ] [ ] Last hospitalization (reason)
Allergy (pls. specify) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing:
ECG Neuropsychiatric exam:
Urinalysis Blood Typing:

Social History
Smoking Y N Age started: Sticks/packs per day:
Alcohol Y N How often: Food preference:

OB Gyn History (pls. encircle) (Female Teachers)


Menarche: Cycle Duration
Parity: F P A L
Papsmear don: Y N if YES, When:
Self Breast examination done: Y N
Mass noted: Y N Specify where
For Male personnel: Digital rectal examination done: Y N

Present Health Status (pls. check) Y N


Cough 2wks 1 month longer
Dizziness [ ] [ ] Lumps
Dyspnea [ ] [ ] Painful urination
Chest/Back pain [ ] [ ] Poor/loss of hearing
Easy fatigability [ ] [ ] Syncope/fainting
Joint/extremity pains [ ] [ ] Convulsions
Blurring of vission [ ] [ ] Malaria
Wearing eyeglasses [ ] [ ] Goiter
Vaginal discharge/bleeding [ ] [ ] Anemia
Dental Status: (pls. specify) Others: Pls. specify)
Present Medication taken: (pls. specify)

Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis


EXG - Electro Cardio Gram F - Full Term
Y - Yes P - Pre-mature
N - No A - Abortion
HPN - Hypertension L - Live Birth
CVD - Cardio Vascular Disease
DM - Diabetes Mellitus Interviewed by:
Date:
Gender: M F
Civil Status S M W S
Years in Service:

Relationship

Y N
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]

Others specify

Packs per year:

Date examined:
Result:

Y N
[ ] [ ]
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