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    CS FORM 86 Medical Certificate 1

    Uploaded by

    Leonor Bagnos
    1) This document is a health examination record that contains information about a person's medical history, physical examination results, laboratory tests, diagnosis, treatment, and remarks from a physician. 2) It includes biographical information like name, date of birth, occupation, as well as vital signs and measurements taken during the physical exam. 3) The physical exam section notes observations of the skin, ears nose and throat, chest, abdomen, genitourinary tract, extremities, and central nervous system, and any lab tests include chest x-rays, urinalysis, and fecalysis.

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

    CS FORM 86 Medical Certificate 1

    Uploaded by

    Leonor Bagnos
    73 views1 page
    1) This document is a health examination record that contains information about a person's medical history, physical examination results, laboratory tests, diagnosis, treatment, and remarks from a physician. 2) It includes biographical information like name, date of birth, occupation, as well as vital signs and measurements taken during the physical exam. 3) The physical exam section notes observations of the skin, ears nose and throat, chest, abdomen, genitourinary tract, extremities, and central nervous system, and any lab tests include chest x-rays, urinalysis, and fecalysis.

    Original Description:

    Medical certificate

    Original Title

    CS-FORM-86-Medical-Certificate-1

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    © © All Rights Reserved

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    1) This document is a health examination record that contains information about a person's medical history, physical examination results, laboratory tests, diagnosis, treatment, and remarks from a physician. 2) It includes biographical information like name, date of birth, occupation, as well as vital signs and measurements taken during the physical exam. 3) The physical exam section notes observations of the skin, ears nose and throat, chest, abdomen, genitourinary tract, extremities, and central nervous system, and any lab tests include chest x-rays, urinalysis, and fecalysis.

    Copyright:

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

    CS FORM 86 Medical Certificate 1

    Uploaded by

    Leonor Bagnos
    1) This document is a health examination record that contains information about a person's medical history, physical examination results, laboratory tests, diagnosis, treatment, and remarks from a physician. 2) It includes biographical information like name, date of birth, occupation, as well as vital signs and measurements taken during the physical exam. 3) The physical exam section notes observations of the skin, ears nose and throat, chest, abdomen, genitourinary tract, extremities, and central nervous system, and any lab tests include chest x-rays, urinalysis, and fecalysis.

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    © All Rights Reserved
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    REVISED FORM 86

    HEALTH EXAMINATION RECORD

    Name: _____________________________________ Region: _________ Division: ___________


    Date of Birth: _______________________ Place of Birth: ______________ Civil Status: ______
    School: _____________________________ Occupation: ____________________ Sex: ______

    Age: _________ Wt: __________ Height: __________ Temperature: ___________


    BP: _____ Pulse Rate ___________________ Respiratory Rate: ___________

    Date of Examination: _________________________________

    Past History:
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________

    PHYSICAL EXAMINATION

    Skin: ___________________________________________________________________________________
    ENT: ___________________________________________________________________________________
    Chest: ___________________________________________________________________________________
     Heart: _________________________________________________________________________________
     Lungs _________________________________________________________________________________
    :
    Abdomen: _________________________________________________________________________________
    Genito Urinary Tract: ____________________________________________________________________
    Extremities: ________________________________________________________________________________
    Central Nervous System: _____________________________________________________________________

    LABORATORY EXAMINATION

    Chest X- ________________________________________________________________________________
    ray:
    Urinalysis _________________________________________________________________________________
    :
    Fecalysis: _________________________________________________________________________________
    Other Lab Exams: ___________________________________________________________________________

    DIAGNOSIS: ____________________________________________________________________________

    TREATMENT: ____________________________________________________________________________

    REMARKS: ____________________________________________________________________________

    ______________________________ ______________________________
    Employee’s Signature Physician’s Signature
    (over printed name) (over printed name)

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