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Health Examination Record

This document contains Mary Joy D. De La Cruz's health examination record. It includes her personal information like name, date of birth, type of work, and civil status. It also contains the results of her health examinations over multiple dates, including measurements of height, weight, blood pressure, and pulse. examination of various body systems like respiratory, circulatory, digestive, genitourinary, skin, locomotor, nervous, eyes, ears, throat, and teeth. It notes any immunizations received and provides the recommending physician's signature.

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mary joy dela cruz
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92 views4 pages

Health Examination Record

This document contains Mary Joy D. De La Cruz's health examination record. It includes her personal information like name, date of birth, type of work, and civil status. It also contains the results of her health examinations over multiple dates, including measurements of height, weight, blood pressure, and pulse. examination of various body systems like respiratory, circulatory, digestive, genitourinary, skin, locomotor, nervous, eyes, ears, throat, and teeth. It notes any immunizations received and provides the recommending physician's signature.

Uploaded by

mary joy dela cruz
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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CS Form 86 HEALTH EXAMINATION RECORD

Name: ________MARY JOY D. DE LA CRUZ__________ Division: _____NEGROS OCCIDENTAL_________________


Department: ______TLE DEPT.___________________

Date of Birth: ________JANUARY 6, 1977______________


Type of Work: ________TEACHING________________ Sex: __FEMALE___ Civil Status: __MARRIED________

Date: Date: Date:


1 Height: Height: Height:

Weight: Weight: Weight:

2 Temperature:

Respiratory System:
3 Fluorography:

Sputum Analysis:

Ciculatory System

Blood Pressure:
4
Pulse:

Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:

5 Digestive System:

Genito-Urinary:
6
Urinalysis, etc.

7 Skin

8 Locomotor System:

9 Nervous System:

Eyes:
10
Conjunctivitis,etc.: Color Perception:

Vision:
11 With glasses: Far: _____ Near: _____ With glasses: Far: _____ Near: _____ With glasses: Far: _____ Near: _____

W/out glasses: Far: _____ Near: _____ W/out glasses: Far: _____ Near: _____ W/out glasses: Far: _____ Near: _____

12 Nose:

13 Ear:

Hearing:
14
Right: Left: Right: Left: Right: Left:

15 Throat:

16 Teeth & Gums:

17 Immunization:

18 Remarks

19 Recommendation

Employee's Signature:
20
Employee's Name (Print):

Physician's Signature:
21
Physician's Name (Print):
Appendix 11
TEACHER'S HEALTH CARD
Date: _____________________________________________
Name: ____MARY JOY D. DE LA CRUZ__________________
School/District/Division: Hinigaran NHS/Hinigaran 1/Div. of Neg. Occ.
Position/Designation: _____TEACHER 1________
First Year in Service: ______June 5, 2017____________

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 Y N
Hypertension Tuberculosis
Asthma Surgical Operations (pls. specify)
Diabetes Mellitus Yellowish discoloration of skin.sclera
Cardiovascular Disease Last hospitalization (reason)
Allergy (pls. specify) ____________________ Others (pls.sprcify) _________________________________

Last Taken Date Result Date Result


CXR/Sputum Result: ______ ______ Drug Testing: ______ ______
ECG ______ ______ Neuropsychiatric exam: ______ ______
Urinalysis ______ ______ Blood Typing: ______ ______
Others (pls.sprcify) _________________________________
Social History
Smoking Y _____ N _____Age started: ____ Sticks/pakcs per day: _____ Packs per year: ______
Alcohol Y _____ N ____ How often: ____________ Food preference: _____________________
OB Gyn History (pls. encircle) (Female Teachers)
Menarche: _______________ Cycle: _____________ Duration _________________________
Parity: F P A L
Papsmear done: Y N if YES, When: _____________________
Self Breast examination done: Y N
Mass noted: Y N Specify where ____________________
For Male personnel: Digital examination done: Y N Date examined: ________ Result: _________________
Present Health Status (pls. check) Y N Y N
Cough 2wks 1mo. longer
Dizziness Lumps
Dyspnea Painful urination
Chest/Back pain Poor/loss of hearing
Easy fatigability Syncope/fainting
Joint/extrimity pains Convulsions
Blurring of vision Malaria
Wearing eyeglasses Goiter
Vaginal discharge/bleeding Anemina
Dental Status: (pls. specify) _______________________________ Others: (pls. specify) ___________________________
Present Medication taken: (pls. specify) ____________________________________________________________________

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


ECG - Electro Cardiogram 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: _________________________________________
__

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