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    Form 86 Physical Exam

    Uploaded by

    RyahNeil Bohol Morales
    This document is a health examination record template used to collect an individual's personal information and results from a physical examination. It includes sections to document findings related to the respiratory, circulatory, digestive, genitourinary, locomotor, and nervous systems as well as eyes, ears, nose, teeth/gums, immunizations, remarks, and recommendations. The examiner would fill in the individual's details and physical assessment.

    Copyright:

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

    Form 86 Physical Exam

    Uploaded by

    RyahNeil Bohol Morales
    52 views2 pages
    This document is a health examination record template used to collect an individual's personal information and results from a physical examination. It includes sections to document findings related to the respiratory, circulatory, digestive, genitourinary, locomotor, and nervous systems as well as eyes, ears, nose, teeth/gums, immunizations, remarks, and recommendations. The examiner would fill in the individual's details and physical assessment.

    Original Description:

    Physical Examination

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    This document is a health examination record template used to collect an individual's personal information and results from a physical examination. It includes sections to document findings related to the respiratory, circulatory, digestive, genitourinary, locomotor, and nervous systems as well as eyes, ears, nose, teeth/gums, immunizations, remarks, and recommendations. The examiner would fill in the individual's details and physical assessment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    52 views2 pages

    Form 86 Physical Exam

    Uploaded by

    RyahNeil Bohol Morales
    This document is a health examination record template used to collect an individual's personal information and results from a physical examination. It includes sections to document findings related to the respiratory, circulatory, digestive, genitourinary, locomotor, and nervous systems as well as eyes, ears, nose, teeth/gums, immunizations, remarks, and recommendations. The examiner would fill in the individual's details and physical assessment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Republic of the Philippines

    Department of Health
    BUREAU OF HEALTH
    Dumaguete City
    ______________________
    (Date)

    This is to certify that Mr./Mrs./Miss _____________________________________________________


    (Name)
    ________________________________________, ________________________________________________
    (Position) (Place of Assignment)
    has submitted for Physical Examination on this date in accordance with Ordinance No. 37, of the Honorable City
    Council, requiring city government teachers and employees of Dumaguete City to undergo physical examination
    every year.

    Remarks: ___________________________________________________________________________

    Recommendation: ____________________________________________________________________

    ___________________________________
    City Health Officer

    Republic of the Philippines


    Department of Health
    BUREAU OF HEALTH
    Dumaguete City
    ______________________
    (Date)

    This is to certify that Mr./Mrs./Miss _____________________________________________________


    (Name)
    ________________________________________, ________________________________________________
    (Position) (Place of Assignment)
    has submitted for Physical Examination on this date in accordance with Ordinance No. 37, of the Honorable City
    Council, requiring city government teachers and employees of Dumaguete City to undergo physical examination
    every year.

    Remarks: ___________________________________________________________________________

    Recommendation: ____________________________________________________________________

    ___________________________________
    City Health Officer
    BUREAU OF HEALTH '.

    MANILA
    HEALTH WAMlNATlON RECORD

    NAME : OFFICE :
    (IfTeacher, what school)
    Address: Type of Work:

    AGE: SEX: CIVIL STATUS: HEIGHT cm. WEIGHT kls.

    1. Respiratory System: 8. Eyes:

    Color Perception
    Flouragraphy:
    R. Lung Vlsion Test Distant Vision
    L. Lung Without Glasses:, R. Eye 1
    Temperature: L.pe
    2. Circulatory System: With Glasses: 8. Eye
    L. Eye
    Blood Pressure: vision'Test: Near Vision
    Systolic: Without Glasses, R. Eye
    Diastolic:' L. Eye
    Pulse: With Glasses R. Eye
    sitting: L. Eye
    Agility Test: 9. Ears:
    After 2 min.
    3. Digestive System: . ... . . .... Hearing:
    ... R. Ear:
    L. Ear:
    Tickling of Watch: R. Ear:
    C L. Ear:
    -
    4. Genito Urinary: Conversion: R. Ear:
    L. Ear:
    10. Nose:

    12. 'Toothand Gums:

    6. Lotomotor System: 13. Immunization:

    14. Remarks:
    7. Nervous System:
    15. Recommendation:

    Date of Examination Signature of Examinee

    Medical Examiner
    ' 11 Thumb mark

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