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    ANNUAL HEALTH Form 4A Form 86 2

    Uploaded by

    JESUS MOSA, JR.
    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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    ANNUAL HEALTH Form 4A Form 86 2

    Uploaded by

    JESUS MOSA, JR.
    116 views1 page
    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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    ANNUAL-HEALTH-Form-4A-Form-86-2

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    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.

    Copyright:

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

    ANNUAL HEALTH Form 4A Form 86 2

    Uploaded by

    JESUS MOSA, JR.
    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.

    Copyright:

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

    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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