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Form 86 Medical Certificate

This document contains a health card template for teachers. It collects personal information like name, date of birth, gender, family medical history, past medical history, social history, and current health status. Examination details include vital signs, vision, hearing, respiratory, circulatory, digestive and other physical assessments.

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NARCISO GALAGALA
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320 views4 pages

Form 86 Medical Certificate

This document contains a health card template for teachers. It collects personal information like name, date of birth, gender, family medical history, past medical history, social history, and current health status. Examination details include vital signs, vision, hearing, respiratory, circulatory, digestive and other physical assessments.

Uploaded by

NARCISO GALAGALA
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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SHD Form 4

TEACHER'S HEALTH CARD


Date: ____________________
Name: ____________________ Date of Birth: Age: Gender:
School/District/Division: ___________________________________________Civil Status
Position/Designation: ___________________________________________ Years in Service:
First Year in Service: ___________________________________________
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) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing: Others specify
ECG Neuropsychiatric exam:
Urinalysis Blood Typing:
Social History
Smoking Y N Age started: Sticks/packs per Packs
day: per year:
Alcohol Y N How often: Food preference:
OB Gyn History (pls. encircle) (Female Teachers)
Menarche: Cycle Duration
Menopause: ________________
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 rectal examination done: Y N Date examined:
Result:

Present Health Status (pls. check) Y N Y N


Cough 2wks 1 month longer
Dizziness [ [] ] Lumps [ ][ ]
Dyspnea [ [] ] Painful urination [ ][ ]
Chest/Back pain [ [] ] Poor/loss of hearing [ ][ ]
Easy fatigability [ [] ] Syncope/fainting [ ][ ]
Joint/extremity pains [ [] ] Convulsions [ ][ ]
Blurring of vission [ [] ] Malaria [ ][ ]
Wearing eyeglasses [ [] ] Goiter [ ][ ]
Vaginal discharge/bleeding [ [] ] Anemia [ ][ ]
Dental Status: (pls. specify) Others: Pls. specify)
Present Medication taken: (pls. specify)
Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis
EXG - Electro Cardio Gram 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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CS Form 86

SHD Form 4-A

HEALTH EXAMINATION RECORD

Name: Division:
Date of Birth: Type of Work:
Civil Status:_____________ Sex:

1 Date:
Height
Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: ________Near: _________
Without glasses: Far: ________Near: _________
12 Nose:
13 Ear:
14 Hearing:
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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