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    Return To Duty Form 86

    Uploaded by

    RA Sunga
    This health examination record contains information about an individual's name, date of birth, sex, civil status, type of work, height, weight, blood pressure, pulse, vision, hearing, respiratory, circulatory, digestive, genital, urinalysis, skin, locomotor, nervous, eyes, ears, nose, throat, teeth and gums, immunization, remarks, recommendation, employee signature and physician's signature. The document collects medical information to assess an individual's fitness for employment.

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

    Return To Duty Form 86

    Uploaded by

    RA Sunga
    2K views1 page
    This health examination record contains information about an individual's name, date of birth, sex, civil status, type of work, height, weight, blood pressure, pulse, vision, hearing, respiratory, circulatory, digestive, genital, urinalysis, skin, locomotor, nervous, eyes, ears, nose, throat, teeth and gums, immunization, remarks, recommendation, employee signature and physician's signature. The document collects medical information to assess an individual's fitness for employment.

    Original Description:

    Return to duty

    Original Title

    Return-to-Duty-Form-86

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    © © All Rights Reserved

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    This health examination record contains information about an individual's name, date of birth, sex, civil status, type of work, height, weight, blood pressure, pulse, vision, hearing, respiratory, circulatory, digestive, genital, urinalysis, skin, locomotor, nervous, eyes, ears, nose, throat, teeth and gums, immunization, remarks, recommendation, employee signature and physician's signature. The document collects medical information to assess an individual's fitness for employment.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    2K views1 page

    Return To Duty Form 86

    Uploaded by

    RA Sunga
    This health examination record contains information about an individual's name, date of birth, sex, civil status, type of work, height, weight, blood pressure, pulse, vision, hearing, respiratory, circulatory, digestive, genital, urinalysis, skin, locomotor, nervous, eyes, ears, nose, throat, teeth and gums, immunization, remarks, recommendation, employee signature and physician's signature. The document collects medical information to assess an individual's fitness for employment.

    Copyright:

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

    General Form 86

    HEALTH EXAMINATION RECORD

    Name: _________________________ Department: DepEd – ____________________


    Date of Birth: __________________________ Sex: ____________________________
    Civil Status: ___________________________ Type of Work: _____________________

    1. Date: ______________________ Height: _______________ Cms: ____________


    2. Temperature: _______________ Age: ______ Weight: _________ Lbs.: ______
    3. Respiratory System: ______________________________________________________
    4. Circulatory System: _______________________________________________________
    5. Blood Pressure: _________________ Systolic: _________ Diastolic: ______________
    Pulse: _____________ Sitting: ______________ Diastolic: ____________________
    After (3) Minutes: _____________ Systolic: _______________
    Blood Analysis: ______________________________________
    Digestive System: ___________________________________
    6. Gentile: ________________________________________________________________
    Urinalysis: ______________________________________________________________
    7. Skin: __________________________________________________________________
    8. Loco-motor System: ______________________________________________________
    9. Nervous System: _________________________________________________________
    10. Eyes Conjective: ________________________________________________________
    11. Color Perception: ________________________________________________________
    12. Vision w/o Glasses: Far: _______ Near: ______ Far: ______ Near: ________
    Far: _______ Near: ______ Far: ______ Near: ________
    13. Ear: __________________________________________________________________
    14. Hearing: _____________ Right Ear: __________ Right Ear: ___________
    Left Ear: ___________ Left Ear: ____________
    15. Nose: _________________________________________________________________
    16. Throat: ________________________________________________________________
    17. Teeth and Gums: ________________________________________________________
    18. Immunization: __________________________________________________________
    19. REMARKS: _____________________________________________________________
    20. RECOMMENDATION: _____________________________________________________

    21. Employee Signature: _____________________


    22. Physician’s Signature: ____________________

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