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ANNUAL HEALTH Form 4A Form 86 2

This document contains a health examination record for an employee. It records information such as the employee's name, contact details, date of birth, height, weight, and measurements of vital signs like blood pressure, pulse, and oxygen saturation. It also notes examination findings for respiratory, circulatory, digestive, genitourinary, skin, locomotor, and nervous systems, as well as for eyes, ears, nose, throat, teeth and gums. Details of Covid vaccinations and booster doses are included. The physician signs off with any findings, recommendations, and their signature and license number.

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JESUS MOSA, JR.
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316 views1 page

ANNUAL HEALTH Form 4A Form 86 2

This document contains a health examination record for an employee. It records information such as the employee's name, contact details, date of birth, height, weight, and measurements of vital signs like blood pressure, pulse, and oxygen saturation. It also notes examination findings for respiratory, circulatory, digestive, genitourinary, skin, locomotor, and nervous systems, as well as for eyes, ears, nose, throat, teeth and gums. Details of Covid vaccinations and booster doses are included. The physician signs off with any findings, recommendations, and their signature and license number.

Uploaded by

JESUS MOSA, JR.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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SHD FORM 4A (CS Form 86)

DepEd- SDO, Surigao City

HEALTH EXAMINATION RECORD

Name: _________________________________________ Contact No:____________________


School: ______________________________ District_____ Designation/Position:___________
Date of Birth: ________________________ Sex: ____ Age: _______ Civil Status: __________
Date examined: ____________________ Height: _______ Weight: ________ BMI ________
Respiratory System: ____________________________________________________________
Circulatory System: ____________________________________________________________
Blood Pressure: _____________ Systolic:________ Diastolic:________ O2 Sat_______
Pulse Setting: _________________ Agility Test: ___________After 3 mins:________
Digestive System: _______________________________________________________________
Genito-Urinary System: _________________________________________________________
Urinalysis, etc: ___________________________________________________________
Skin: _________________________________________________________________________
Loco-Motor System: ____________________________________________________________
Nervous System: _______________________________________________________________
Eyes: Conjunctiva: etc: _________________________________________________________
Color Perception: ______________________________________________________________
VISION Without glasses Far: _______________ Near: _______________________
With glasses Far: _______________ Near: _______________________
Ears: _________________________________________________________________________
Hearing: _____________________ Right Ear: ________________ Left Ear: ______________
Nose: _________________________________________________________________________
Throat: _______________________________________________________________________

Teeth and Gum: ________________________________________________________________

Type of Covid Vaccine__________________ 1st Dose Date____________2nd dose date__________

Booster Dose Vaccine/ Date__________________________ FBS: _______________________

Fluoroscopy: __________________________________________________________________

Findings/Remarks:______________________________________________________________

Recommendation:_______________________________________________________________

Employee’s Signature: ________________________

___________________________________
Physician’s Signature over Printed Name
License Number: ____________

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