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    Form-86 Medical Return To Duty

    Uploaded by

    EDERLYN ARMILLO
    return to duty

    Copyright:

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

    Form-86 Medical Return To Duty

    Uploaded by

    EDERLYN ARMILLO
    77 views1 page
    return to duty

    Original Title

    FORM-86 MEDICAL RETURN TO DUTY

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    return to duty

    Copyright:

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

    Form-86 Medical Return To Duty

    Uploaded by

    EDERLYN ARMILLO
    return to duty

    Copyright:

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

    Form 86

    REPUBLIC OF THE PHILIPPINES


    Department of Health
    REGION V (Bicol)

    Name: EDERLYN ARMILLO_ Office: DEPARTMENT OF EDUCATION


    Address: HARIGUE LIBON ALBAY Type of Work : PUBLIC SCHOOL TEACHER
    Age: 29 Sex: FEMALE Civil Status: MARRIED
    Weight:__________________ Height:______________ Nationality: FILIPINO
    ______________________________________________________________________________________

    1. Respiratory System:_______________________________ 8. Eyes:_________________________


    _______________________________________________ ______________________________
    Flouroscope:_______________________________________ Color Perception:_________________
    Vision Test:______________________
    R-Lung:_____________________________________ Without Classes
    ___________________________________________ DV R__________________
    L__________________
    L-Lung:_____________________________________ LV R__________________
    ____________________________________________ L__________________
    2. Circulatory System:_______________________________ 9. Ears:_________________________
    ________________________________________________ Hearing R__________________
    Blood Pressure:_______________________________ L__________________
    Systolic:_______________________________ Tickling of Watch R___________
    Diastolic:______________________________ L___________
    Pulse Conversation R___________
    Sitting:________________________________ L___________
    Agility Test:____________________________
    After 2 Minutes:_________________________ 10. Nose:________________________
    3. Digestive System:_________________________________
    ________________________________________________ 11. Throat:______________________
    4. Monitor Urinary:_________________________________ 12. Teeth and Gums:______________
    ________________________________________________
    URINALYSYS 13. CDT Immunization:___________
    Color:_________________________________
    Function:______________________________ 14. Small Pox Immunization:_______
    Sugar:___________ Albumin:____________
    Blood:___________ 15. Remarks:____________________
    Pulse:___________ Others:______________ _____________________________
    5. Skin____________________________________________ 16. Recommendation(s):___________
    6. Locomotor System:________________________________ _____________________________
    7. Nervous System:__________________________________ _____________________________
    Other Findings:_______________________________ _____________________________
    ____________________________________________
    Purpose:_____________________________________
    ____________________________________________
    ____________________________________________ _____________________________
    (Signature of Examinee)

    Right Hand Thumbmark:


    _____________________________
    Physician
    _____________________________
    _____________________________
    _____________________________
    Date:_________________________________ Address

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