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    Cs Form No. 86 Health Examination Card

    Uploaded by

    Lynneth Esguerra
    This document contains a health examination card that collects an employee's personal and medical information over multiple visits. The card tracks details like height, weight, blood pressure, vision, hearing, immunizations, and physician notes and recommendations. It is used to document an employee's health status and fitness for their type of work.

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

    Cs Form No. 86 Health Examination Card

    Uploaded by

    Lynneth Esguerra
    26 views1 page
    This document contains a health examination card that collects an employee's personal and medical information over multiple visits. The card tracks details like height, weight, blood pressure, vision, hearing, immunizations, and physician notes and recommendations. It is used to document an employee's health status and fitness for their type of work.

    Original Description:

    Health Examination Card

    Original Title

    cs_form_no._86_health_examination_card

    Copyright

    © © All Rights Reserved

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    This document contains a health examination card that collects an employee's personal and medical information over multiple visits. The card tracks details like height, weight, blood pressure, vision, hearing, immunizations, and physician notes and recommendations. It is used to document an employee's health status and fitness for their type of work.

    Copyright:

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

    Cs Form No. 86 Health Examination Card

    Uploaded by

    Lynneth Esguerra
    This document contains a health examination card that collects an employee's personal and medical information over multiple visits. The card tracks details like height, weight, blood pressure, vision, hearing, immunizations, and physician notes and recommendations. It is used to document an employee's health status and fitness for their type of work.

    Copyright:

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

    CS Form 86

    HEALTH EXAMINATION CARD

    Name: ____________________________________________________
    Division: _______________________________________________________________________
    Department: __________________________________
    Date of Birth: ________________________________________________
    Type of Work: _________________________________________________________________
    Sex: _____________________
    Civil Status: _________________

    1 Date: Date: Date:


    Height Height Height
    Weight Weight Weight
    2 Temperature:
    3 Respiratory System:
    Fluorography:
    Sputum Analysis:
    4 Circulatory System:
    Blood Pressure:
    Pulse:
    Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
    5 Digestive System:
    6 Genito-Urinary:
    Urinalysis, etc.:
    7 Skin:
    8 Locomotor System:
    9 Nervous System:
    10 Eyes: Conjunctivitis, etc.
    Color Perception:
    11 Vision:
    With glasses: Far: _______ Near: _______ With glasses: Far: _______ Near: _______ With glasses: Far: _______ Near: _______
    Without glasses: Far: _______ Near: _______ Without glasses: Far: _______ Near: _______ Without glasses: Far: _______ Near: _______
    12 Nose:
    13 Ear:
    14 Hearing:
    Right: Left: Right: Left: Right: Left:
    15 Throat:
    16 Teeth and Gums:
    17 Immunization:
    18 Remarks:
    19 Recommendation
    20 Employee's Signature:
    Employee's Name (Print):
    21 Physician's Signature:
    Physician's Name (Print):

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