CS FORM 86 HEALTH EXAMINATION RECORD

Name: _________________ Division: Department: ________________________________________

Date of Birth: __________ Type of Work: Sex:____ Civil Status: ______________

Date: Date: Date:

1 Height Height Height
Weight Weight Weight
2 Temperature:
Respiratory System:
3 Fluorography:
Sputum Analysis:
Circulatory 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: Conjunctivitis, etc.:
10
Color Perception:
Vision:
11 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:
Hearing:
14
Right: Left: Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks:
19 Recommendation:
Employee’s Signature
20
Employee’s Name (Print)
Physician’s Signature
21
Physician’s Name (Print)