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    CS FORM 86 Medical Certificate 1 1

    Uploaded by

    Jinky Sumagaysay Joeamil
    The document is a health form that collects information about a patient such as name, date of birth, medical history, physical examination results, lab tests, diagnosis, treatment, and signatures of the employee and physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    CS FORM 86 Medical Certificate 1 1

    Uploaded by

    Jinky Sumagaysay Joeamil
    39 views1 page
    The document is a health form that collects information about a patient such as name, date of birth, medical history, physical examination results, lab tests, diagnosis, treatment, and signatures of the employee and physician.

    Original Title

    CS-FORM-86-Medical-Certificate-1-1

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    The document is a health form that collects information about a patient such as name, date of birth, medical history, physical examination results, lab tests, diagnosis, treatment, and signatures of the employee and physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    39 views1 page

    CS FORM 86 Medical Certificate 1 1

    Uploaded by

    Jinky Sumagaysay Joeamil
    The document is a health form that collects information about a patient such as name, date of birth, medical history, physical examination results, lab tests, diagnosis, treatment, and signatures of the employee and physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    REVISED FORM 86

    Department of Education
    HEALTH AND NUTRITION CENTER

    Name: _____________________________________ Region: SOCCSKSARGEN Division: SARANGANI


    Date of Birth: _______________________ Place of Birth: ______________ Civil Status: ______
    School: _____________________________ Occupation: ____________________ Sex: ______

    Age: _________ Wt: __________ Height: __________ Temperature: ___________


    BP: _____ Pulse Rate ___________________ Respiratory Rate: ___________

    Date of Examination: _________________________________

    Past History:
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________

    PHYSICAL EXAMINATION

    Skin: ___________________________________________________________________________________
    ENT: ___________________________________________________________________________________
    Chest: ___________________________________________________________________________________
    • Heart: _________________________________________________________________________________
    • Lungs: _________________________________________________________________________________
    Abdomen: _________________________________________________________________________________
    Genito Urinary Tract: ____________________________________________________________________
    Extremities: ________________________________________________________________________________
    Central Nervous System: _____________________________________________________________________

    LABORATORY EXAMINATION

    Chest X-ray: ________________________________________________________________________________


    Urinalysis: _________________________________________________________________________________
    Fecalysis: _________________________________________________________________________________
    Other Lab Exams: ___________________________________________________________________________

    DIAGNOSIS: ____________________________________________________________________________

    TREATMENT: ____________________________________________________________________________

    REMARKS: ____________________________________________________________________________

    ______________________________ ______________________________
    Employee’s Signature Physician’s Signature
    (over printed name) (over printed name)

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