General Form 86

Republic of the Philippines
Department of Education
REGION XI
SCHOOLS DIVISION OF DAVAO ORIENTAL
General Form 86
HEALTH EXAMINATION RECORD
NAME: _________________________________ DEPARTMENT: Department of Education

SCHOOL: ________________________________ DISTRICT: ________________________
DATE OF BIRTH: __________________________ SEX: ________CIVIL STATUS: ________
1. Date: ______________ Height: ______ Weight: ________ BMI: ________

2. Temperature: _________________________________________________________________
3. Respiratory System: ____________________________________________________________
4. Fluorography Result: __________________________ Where: ____________________________
(Chest X-ray) Film #: ____________________ Date Taken: _______________________
Sputum Analysis: ______________________________
5. Circulatory System: ___________________________ Blood Pressure:___________________________

6. Digestive System: _________________________________________________________________________
7. Genitourinary: ____________________________________________________________________________
8. Urinalysis: ________________________________________________________________________________
9. Skin: ______________________________________________________________________________________
10. Locomotor: ______________________________________________________________________________
11. Nervous System: _________________________________________________________________________
12. Eyes, Conjunctiva, etc.: _________________________________________________________________
13. Color Perception: ________________________________________________________________________
14. Vision: With Glasses: Far: _______________ Near: ____________________________________
Without Glasses: Far: ____________ Near: ____________________________________
15. Nose: ____________________________________________________________________________________
16. Ear: ______________________________________________________________________________________
17. Hearing: _________________________________________________________________________________
18. Throat: __________________________________________________________________________________
19. Immunization: ___________________________________________________________________________
20. Teeth and Gums:_________________________________________________________________________
Recommendation: ______________________________________________________________
21. Employee’s Signature: _______________________________________________

22. Employee’s Printed Name: ____________________________________________
23. Physician’s Signature: _____________________________________________

24. Physician’s Name: _____________________________________ License No.: ______________
INSTRUCTION FOR FILING
1.) Record main activity and not the official designation. Example: letter carrier, messenger,
telephone operator, typist, executive, etc.
2.) Include larynx, broncho 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 findings.
3.) Include test for recuperative power of the heart and blood pressure. Record important history
and abnormal findings.
4.) Include examination for hernia, anus, inflammation of the gall bladder, appendix and
enlargement of the spleen.
5.) Indicate necessity for laboratory examination when needed and cannot be done due to lack of
facilities.
6.) Include test for flexibility and joints reflexes. Record important history and abnormal
findings.
7.) Test for Argyll Robertson and romberg’s signs.
8.) Indicate necessity for specialist examination if symptoms warrant and do facilities are
available.
9.) Use ordinary conversational voice at 6 meters. Test one ear at a time. Record important
history and abnormal findings.
10.) Look especially for pyorrhea.
11.) Record date of immunization against cholera, dysentery, and typhoid.
12.) Record abnormal findings, temporary or permanent, unfitness, for work contagious
condition, etc.
13.) Record if employee needs medical treatment, vacation, separation from service or
improvement of certain habits.
14.) Employee must sign in the presence of examining physicians.
Note: All entries must be written in ink. Any erasure or correction must be signed by the
physician.

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Republic of the Philippines

HEALTH EXAMINATION RECORD

NAME: _________________________________ DEPARTMENT: Department of Education

1. Date: ____ Height: Weight: BMI:

Sputum Analysis: ______________________________

5. Circulatory System: _ Blood Pressure:_

21. Employee’s Signature: _______________________________________________

23. Physician’s Signature: _____________________________________________

7.) Test for Argyll Robertson and romberg’s signs.

10.) Look especially for pyorrhea.

11.) Record date of immunization against cholera, dysentery, and typhoid.

14.) Employee must sign in the presence of examining physicians.

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