REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
KIDAPAWAN CITY DIVISION

ATHLETES DOCUM
*IMPORTANT*
1. FILL ALL ATHLETE'S DATA ATHLETE 1 DUMAGUIT ATHLETE 10
ATHLETE 2 MARTINITO ATHLETE 11
ATHLETE 3 ORO ATHLETE 12
*PRINTING* ATHLETE 4 BAYNOSA ATHLETE 13
1. CLICK ATHLETE 1, ETC… ATHLETE 5 ADANG ATHLETE 14
2. HIT Ctrl. + P. ATHLETE 6 COMPLETADO ATHLETE 15
3. Hit ENTER ATHLETE 7 0 ATHLETE 16
* COACHES & CHAPERON REQUIREMENTS ARE IN THE GALLERY. ATHLETE 8 0 ATHLETE 17
ATHLETE 9 0 ATHLETE 18
IMPORTANT: DO NOT DRAG DATA, JUST COPY AND PASTE.

RONALD S. RAMONES-KIDAPAWAN CITY

HE PHILIPPINES
OF EDUCATION
SARGEN
CITY DIVISION

DOCUMENTS
0 ATHLETES DATA
0
0 GALLERY
0
0 ID PICTURES
0
0 Note:
0 If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
0 If parents are abroad, Special Power of Attorney (SPA) is needed.

PARENTAL CONSENT MUST BE SIGNED BY MOTHER AND

FATHER. IF DECEASED, SECURE DEATH CERTIFICATE.
 BACK
YEAR Region Level Event Last Name First Name

1 2019 XII SECONDARY SEPAK TAKRAW DUMAGUIT KENNETH

2 2019 XII SECONDARY SEPAK TAKRAW MARTINITO PAOLO
3 2019 XII SECONDARY SEPAK TAKRAW ORO MARK LOUI
4 2019 XII SECONDARY SEPAK TAKRAW BAYNOSA MIKE JAY
5 2019 XII SECONDARY SEPAK TAKRAW ADANG JOVAN
6 2019 XII SECONDARY SEPAK TAKRAW COMPLETADO JOMARI
7 2019 XII
8 2019 XII
9 2019 XII
10 2019 XII
11 2019 XII
12 2019 XII
13 2019 XII
14 2019 XII
15 2019 XII
16 2019 XII
17 2019 XII
18 2019 XII
COACH BENZAR A. SUMAGKA
CO-COACH
CHAPERON
REGION XII
DIVISION SARANGANI
DATE 6/9/2019
DSAC MEILANI L.LIBRE Name of Coach
DENTIST MACAMAY JIMENEZ
DOCTOR
DSO EDMUND GULAM
RSO

Participation to previous Palarong Pambansa

Year of Participation Event Venue Remarks
 Bdate
MI Sex Schoolname School Type School Address
mm/dd/yyyy

M MALE 03/7/2004 KAWAS NHS PUBLIC KAWAS, ALABEL

B. MALE 08/09/2005 KAWAS NHS PUBLIC KAWAS, ALABEL
J. MALE 03/21/2003 KAWAS NHS PUBLIC KAWAS, ALABEL
G. MALE 04/21/2003 KAWAS NHS PUBLIC KAWAS, ALABEL
S. MALE 05/10/2004 KAWAS NHS PUBLIC KAWAS, ALABEL
MALE 04/08/2004 KAWAS NHS PUBLIC KAWAS, ALABEL

Athletic Meet REMARKS Remarks-PARENTAL CONSENT (A1)

INTRAMURALS
DISTRICT MEET
DISTRICT MEET 1ST

Remarks-PARENTAL CONSENT (A2)

Remarks-PARENTAL CONSENT (A3)

Remarks-PARENTAL CONSENT (A4)

Remarks-PARENTAL CONSENT (A5)
 SchDiv school code LRN PLACE OF BIRTH

SARANGANI 304526 PRK.4 KAWAS, ALABEL

SARANGANI 304526 BUYO, KAWAYAN BILIRAN
SARANGANI 304526 PRK.2 KAWAS, ALABEL
SARANGANI 304526 LAGO, KAWAS, ALABEL
SARANGANI 304526 PRK.7 BAYBAY KAWAS, ALABEL
SARANGANI 304526 PRK.1 KAWAS, ALABEL

Remarks-PARENTAL CONSENT (A6) Remarks-PARENTAL CONSENT (A11)

Remarks-PARENTAL CONSENT (A7) Remarks-PARENTAL CONSENT (A12)

Remarks-PARENTAL CONSENT (A8) Remarks-PARENTAL CONSENT (A13)

Remarks-PARENTAL CONSENT (A9) Remarks-PARENTAL CONSENT (A14)

Remarks-PARENTAL CONSENT (A10) Remarks-PARENTAL CONSENT (A15)
 FATHER MOTHER GUARDIAN
ROMEL DUMAGUIT ANIE M. MAHAIT
ROLANDOF. MARTINITO MARILYN T. BAYRE
AGUSTIN S. ORO JR. LULUBELLE B. JOROLAN
CAMELO M. BAYNOSA MELROSE P. GARCIA
NARCISO P. ADANG ALFIE S. SULLA
JONATHAN B. DOMERE MARIBEL O. COMPLETADO

Remarks-PARENTAL CONSENT (A11) Remarks-PARENTAL C

Remarks-PARENTAL CONSENT (A12) Remarks-PARENTAL C

Remarks-PARENTAL CONSENT (A13) Remarks-PARENTAL C

Remarks-PARENTAL CONSENT (A14)

Remarks-PARENTAL CONSENT (A15)
 RELATIONSHIP HOME ADDRESS
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL

Remarks-PARENTAL CONSENT (A16)

Remarks-PARENTAL CONSENT (A1)7

Remarks-PARENTAL CONSENT (A18)

 ADDRESS OF PARENTS/GUARDIAN GRADE SECTION ADVISER
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL
KAWAS, ALABEL
 REGISTRAR/PRINCIPAL SCHOOL YEAR INTRAMURALS DISTRICT/MUNICIPAL
SUSANA S. SUMAGKA 2019-2020
SUSANA S. SUMAGKA 2019-2020
SUSANA S. SUMAGKA 2019-2020
SUSANA S. SUMAGKA 2019-2020
SUSANA S. SUMAGKA 2019-2020
SUSANA S. SUMAGKA 2019-2020
 INCLUSIVE DATES
CONGRESSIONAL/AREA MEET PROVINCIAL/DIVISION/CITY MEET SRAA
PALARONG PAMBANSA Contact Number
 XII
REGION
SARANGANI
DIVISION

SEPAK TAKRAW
EVENT

COACH/ASST. COACH/CHAPERON RECORD

(CERTIFICATE OF TRAINING, RELEVANT COACHING
EXPERIENCE )

CONTRACT OF SERVICE (FOR PRIVATE)

OMNIBUS AFFIDAVIT
MEDICAL CERTIFICATE Assistant Coach/Co-Coach

BENZAR A. SUMAGKA, NAME ,

0 SCHOOL 0

COACH/ASST. COACH/CHAPERON RECORD

(CERTIFICATE OF TRAINING, RELEVANT COACHING
EXPERIENCE )

CONTRACT OF SERVICE (FOR PRIVATE)

OMNIBUS AFFIDAVIT
CHAPERON MEDICAL CERTIFICATE
CERTIFICATE OF COMMITMENT

, NAME
0 SCHOOL

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
PARENTS CONSENT
athlete
athlete MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

DUMAGUIT, KENNETH M NAME OF ATHLETE ORO, MARK LOUI J.

0 LRN 0
03/7/2004 DATE OF BIRTH 03/21/2003
KAWAS NHS SCHOOL KAWAS NHS

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete
A2 PARENTS CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

MARTINITO, PAOLO B. NAME OF ATHLETE BAYNOSA, MIKE JAY G.

0 LRN 0
08/09/2005 DATE OF BIRTH 04/21/2003
KAWAS NHS SCHOOL KAWAS NHS
All athlete interviewed and OK.
SIGNED:
DATE:
XII
REGION
SARANGANI
DIVISION

SEPAK TAKRAW
EVENT

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete athlete
PARENTS CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

ADANG, JOVAN S. NAME OF ATHLETE ,

0 LRN 0
05/10/2004 DATE OF BIRTH 12/30/1899
KAWAS NHS SCHOOL 0

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

COMPLETADO, JOMARI NAME OF ATHLETE ,

0 LRN 0
04/08/2004 DATE OF BIRTH 12/30/1899
KAWAS NHS SCHOOL 0

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED
 , NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
All athlete interviewed and OK.
SIGNED:
DATE:
XII
REGION
SARANGANI
DIVISION

SEPAK TAKRAW
EVENT

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED

, NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL

AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
 INTERVIEWED

, NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
All athlete interviewed and OK.
SIGNED:
DATE:
BACK
 BACK

A1 A7 A13

A2 A8 A14

A3 A9 A15

A4 A10 A16

A5 A11 A17

A6 A12 A18
COACH COACH/ASST.COACH CHAPERON
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: DUMAGUIT KENNETH

(Last) (First)

Sex: MALE Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth: Place of
(mm/dd/yyyy) 03/7/2004 Age: 15 Birth: PRK.4 KAWAS, ALABEL
School: KAWAS NHS Grade Level 0
Address of School: KAWAS, ALABEL
Present Address: KAWAS, ALABEL
Parents: ROMEL DUMAGUIT ANIE M. MAHAIT
Fathers Name Mother/Guardian
Address of Parents: KAWAS, ALABEL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SEPAK TAKRAW INTRAMURALS 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 1ST
December 30, 1899 SEPAK TAKRAW 0 0
SEPAK TAKRAW 0 0
SEPAK TAKRAW
(Use separate sheet if necessary)
DUMAGUIT, KENNETH M
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regiona
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
 0 0 EDMUND GULAM 0

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: DUMAGUIT, KENNETH M Age: 15

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 DUMAGUIT, KENNETH M ROMEL DUMAGUIT ANIE M. MAHAIT
Signature of Learner over printed name Signature of Parent/Guardian over printed name

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: DUMAGUIT, KENNETH M Age: 15

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019
To Whom It May Concern:

This is to certify that DUMAGUIT, KENNETH M

been enrolled at the beginning of the current school year and has attended classes up to this date.

0 SUSANA S. SUMAGKA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
ECORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

PARENT'S CONSENT
M I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) DUMAGUIT, KENNETH M in SEPAK TAKRAW
0 up to the Palarong Pambansa.

KAWAS, ALABEL
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.
AHAIT
ardian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e table below

Remarks
0 ROMEL DUMAGUIT ANIE M. MAHAI
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 SUSANA S.
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

n the lower meets.

Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 0

Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
___

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: DUMAGUIT, KENNETH M 06/09/2019

Age: 15 Sex: MALE Birth Date: 03/7/2004 DATE
Event: SEPAK TAKRAW
Parent/Guardian: ROMEL DUMAGUIT ANIE M. MAHAIT
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
 FOR EXTRACTION MAL -
MALOCLUSSION xt
F - TOOTH INDICATED FLU -
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm -
MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
ANIE M. MAHAIT (√) - SOUND ERUPTED PERMANENT ZOE
over printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal
 Pulse/Blood pressure(record) Normal Abnormal
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: DUMAGUIT, KENNETH M Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: ROMEL DUMAGUIT ANIE M. MAHAIT

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

CE CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that DUMAGUIT, KENNETH M
has
to this date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

SUSANA S. SU
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

E M. MAHAIT
other Over Printed Name

SUSANA S. SUMAGKA
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
 - EXTRACTED TEMPORARY TOOTH
- AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

ANA S. SUMAGKA
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: MARTINITO PAOLO

(Last) (First)

Sex: MALE Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 08/09/2005 Age: 14 Place of Birth: PRK.4 KAWAS, ALABEL
School: KAWAS NHS Grade Level 0
Address of School: KAWAS, ALABEL
Present Address: KAWAS, ALABEL
Parents: ROLANDOF. MARTINITO MARILYN T. BAYRE
Fathers Name Mother/Guardian
Address of Parents: KAWAS, ALABEL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SEPAK TAKRAW INTRAMURALS 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 1ST
December 30, 1899 SEPAK TAKRAW 0 0
SEPAK TAKRAW 0 0
SEPAK TAKRAW
(Use separate sheet if necessary)
MARTINITO, PAOLO B.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: MARTINITO, PAOLO B. Age: 14

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 MARTINITO, PAOLO B. ROLANDOF. MARTINITO MARILYN T. BAY
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: MARTINITO, PAOLO B. Age: 14

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that MARTINITO, PAOLO B.
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 SUSANA S. SUMAGKA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

PARENT'S CONSENT
B. I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) MARTINITO, PAOLO B. in SEPAK TAKRAW
0 up to the Palarong Pambansa.
AWAS, ALABEL
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.
BAYRE
rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 ROLANDOF. MARTINITO MARILYN T. BAYR
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 SUSANA S.
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: MARTINITO, PAOLO B. 06/09/2019

Age: 14 Sex: MALE Birth Date: 03/7/2004 DATE
Event: SEPAK TAKRAW
Parent/Guardian: ROLANDOF. MARTINITO MARILYN T. BAYRE
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
ARILYN T. BAYRE (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: MARTINITO, PAOLO B. Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: ROLANDOF. MARTINITO MARILYN T. BAYRE

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that MARTINITO, PAOLO B.
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

SUSANA S. SU
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

RILYN T. BAYRE
other Over Printed Name

SUSANA S. SUMAGKA
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

ANA S. SUMAGKA
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: ORO MARK LOUI

(Last) (First)

Sex: MALE Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 03/21/2003 Age: 16 Place of Birth: PRK.2 KAWAS, ALABEL
School: KAWAS NHS Grade Level 0
Address of School: KAWAS, ALABEL
Present Address: KAWAS, ALABEL
Parents: AGUSTIN S. ORO JR. LULUBELLE B. JOROLAN
Fathers Name Mother/Guardian
Address of Parents: KAWAS, ALABEL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SEPAK TAKRAW INTRAMURALS 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 1ST
December 30, 1899 SEPAK TAKRAW 0 0
SEPAK TAKRAW 0 0
SEPAK TAKRAW
(Use separate sheet if necessary)
ORO, MARK LOUI J.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: ORO, MARK LOUI J. Age: 16

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 DUMAGUIT, KENNETH M AGUSTIN S. ORO JR. LULUBELLE B. JOR
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: ORO, MARK LOUI J. Age: 16

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ORO, MARK LOUI J.
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 SUSANA S. SUMAGKA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

PARENT'S CONSENT
J. I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) ORO, MARK LOUI J. in SEPAK TAKRAW
0 up to the Palarong Pambansa.
AWAS, ALABEL
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.
JOROLAN
rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 AGUSTIN S. ORO JR. LULUBELLE B. JORO
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 SUSANA S.
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: ORO, MARK LOUI J. 06/09/2019

Age: 16 Sex: MALE Birth Date: 03/21/2003 DATE
Event: SEPAK TAKRAW
Parent/Guardian: AGUSTIN S. ORO JR. LULUBELLE B. JOROLAN
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
UBELLE B. JOROLAN (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: ORO, MARK LOUI J. Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: AGUSTIN S. ORO JR. LULUBELLE B. JOROLAN

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ORO, MARK LOUI J.
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

SUSANA S. SU
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

ELLE B. JOROLAN
other Over Printed Name

SUSANA S. SUMAGKA
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

ANA S. SUMAGKA
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: BAYNOSA MIKE JAY

(Last) (First)

Sex: MALE Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 04/21/2003 Age: 16 Place of Birth: LAGO, KAWAS, ALABEL
School: KAWAS NHS Grade Level 0
Address of School: KAWAS, ALABEL
Present Address: KAWAS, ALABEL
Parents: CAMELO M. BAYNOSA MELROSE P. GARCIA
Fathers Name Mother/Guardian
Address of Parents: KAWAS, ALABEL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SEPAK TAKRAW INTRAMURALS 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 1ST
December 30, 1899 SEPAK TAKRAW 0 0
SEPAK TAKRAW 0 0
SEPAK TAKRAW
(Use separate sheet if necessary)
BAYNOSA, MIKE JAY G.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: BAYNOSA, MIKE JAY G. Age: 16

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 BAYNOSA, MIKE JAY G. CAMELO M. BAYNOSA MELROSE P. GAR
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: BAYNOSA, MIKE JAY G. Age: 16

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that BAYNOSA, MIKE JAY G.
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 SUSANA S. SUMAGKA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

PARENT'S CONSENT
G. I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) BAYNOSA, MIKE JAY G. in SEPAK TAKRAW
0 up to the Palarong Pambansa.
KAWAS, ALABEL
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.
GARCIA
rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 CAMELO M. BAYNOSA MELROSE P. GARC
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 SUSANA S.
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: BAYNOSA, MIKE JAY G. 06/09/2019

Age: 16 Sex: MALE Birth Date: 04/21/2003 DATE
Event: SEPAK TAKRAW
Parent/Guardian: CAMELO M. BAYNOSA MELROSE P. GARCIA
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
ELROSE P. GARCIA (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: BAYNOSA, MIKE JAY G. Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: CAMELO M. BAYNOSA MELROSE P. GARCIA

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that BAYNOSA, MIKE JAY G.
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

SUSANA S. SU
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

ROSE P. GARCIA
other Over Printed Name

SUSANA S. SUMAGKA
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

ANA S. SUMAGKA
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: ADANG JOVAN

(Last) (First)

Sex: MALE Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 05/10/2004 Age: 15 Place of Birth: PRK.7 BAYBAY KAWAS, ALAB
School: KAWAS NHS Grade Level 0
Address of School: KAWAS, ALABEL
Present Address: KAWAS, ALABEL
Parents: NARCISO P. ADANG ALFIE S. SULLA
Fathers Name Mother/Guardian
Address of Parents: KAWAS, ALABEL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SEPAK TAKRAW INTRAMURALS 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 1ST
December 30, 1899 SEPAK TAKRAW 0 0
SEPAK TAKRAW 0 0
SEPAK TAKRAW
(Use separate sheet if necessary)
ADANG, JOVAN S.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: ADANG, JOVAN S. Age: 15

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 ADANG, JOVAN S. NARCISO P. ADANG ALFIE S. SULL
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: ADANG, JOVAN S. Age: 15

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ADANG, JOVAN S.
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 SUSANA S. SUMAGKA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

PARENT'S CONSENT
S. I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) ADANG, JOVAN S. in SEPAK TAKRAW
0 up to the Palarong Pambansa.
AY KAWAS, ALABEL
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.
ULLA
rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 NARCISO P. ADANG ALFIE S. SULLA
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 SUSANA S.
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: ADANG, JOVAN S. 06/09/2019

Age: 15 Sex: MALE Birth Date: 05/10/2004 DATE
Event: SEPAK TAKRAW
Parent/Guardian: NARCISO P. ADANG ALFIE S. SULLA
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
ALFIE S. SULLA (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: ADANG, JOVAN S. Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: NARCISO P. ADANG ALFIE S. SULLA

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ADANG, JOVAN S.
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

SUSANA S. SU
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

FIE S. SULLA
other Over Printed Name

SUSANA S. SUMAGKA
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

ANA S. SUMAGKA
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: COMPLETADO JOMARI

(Last) (First)

Sex: MALE Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 04/08/2004 Age: 15 Place of Birth: PRK.1 KAWAS, ALABEL
School: KAWAS NHS Grade Level 0
Address of School: KAWAS, ALABEL
Present Address: KAWAS, ALABEL
Parents: JONATHAN B. DOMERE MARIBEL O. COMPLETADO
Fathers Name Mother/Guardian
Address of Parents: KAWAS, ALABEL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SEPAK TAKRAW INTRAMURALS 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 0
December 30, 1899 SEPAK TAKRAW DISTRICT MEET 1ST
December 30, 1899 SEPAK TAKRAW 0 0
SEPAK TAKRAW 0 0
SEPAK TAKRAW
(Use separate sheet if necessary)
COMPLETADO, JOMARI
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: COMPLETADO, JOMARI Age: 15

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 COMPLETADO, JOMARI JONATHAN B. DOMERE MARIBEL O. COMPL
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: COMPLETADO, JOMARI Age: 15

Home Address: KAWAS, ALABEL Gender: MALE
School: KAWAS NHS
School Address: KAWAS, ALABEL
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that COMPLETADO, JOMARI
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 SUSANA S. SUMAGKA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) COMPLETADO, JOMARI in SEPAK TAKRAW
0 up to the Palarong Pambansa.
AWAS, ALABEL
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.
MPLETADO
rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 JONATHAN B. DOMERE MARIBEL O. COMPLE
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 SUSANA S.
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: COMPLETADO, JOMARI 06/09/2019

Age: 15 Sex: MALE Birth Date: 04/08/2004 DATE
Event: SEPAK TAKRAW
Parent/Guardian: JONATHAN B. DOMERE MARIBEL O. COMPLETADO
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
IBEL O. COMPLETADO (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: COMPLETADO, JOMARI Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: JONATHAN B. DOMERE MARIBEL O. COMPLETADO

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
KAWAS NHS
School
KAWAS, ALABEL
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that COMPLETADO, JOMARI
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

SUSANA S. SU
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

L O. COMPLETADO
other Over Printed Name

SUSANA S. SUMAGKA
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

ANA S. SUMAGKA
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: KAWAS, ALABEL
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: DUMAGUIT 0
16 (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: KAWAS, ALABEL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
DUMAGUIT, KENNETH M
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
January 16, 1900 0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: KAWAS NHS
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
DUMAGUIT, KENNETH M
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)
Revised July 2019

AR-I (ATHLETE RECORD)

XII
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: 0 0
(Last) (First)

Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 0 INTRAMURALS 0
December 30, 1899 0 DISTRICT MEET 0
December 30, 1899 0 DISTRICT MEET 1ST
December 30, 1899 0 0 0
0 0 0
0
(Use separate sheet if necessary)
DUMAGUIT, KENNETH M
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of R
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO
(DSO)
0 JIMENEZ EDMUND GULAM 0
0 0 EDMUND GULAM 0
0 0 EDMUND GULAM 0
 (Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
 , 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

Name: , Age: 119

Home Address: 0 Gender: 0
School: 0
School Address: 0
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES

Pupils equally reactive to light and accommodation: YES NO

 REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3

KNEE 0/1/2/3 0/1/2/3

MOTOR:

HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY

0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

Republic of the Philippines

DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: 06/09/2019

To Whom It May Concern:

 This is to certify that ,
been enrolled at the beginning of the current school year and has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 HOME Republic of the Philippines
CORD) DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0 up to the Palarong Pambansa.
0
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.

rdian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act

e below

Remarks
0 0 0
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
0
Remarks Signature of Guardian over Printed Name
0
0 0
1ST (Relationship with the Athlete)
0
0 0 0
Adviser School Hea
(Signature Over Printed Name) (Signature Ove

lower meets.
Remarks:
e and Signature of Regional
Sports Officer (RSO)

0
 Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
__

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , 06/09/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0
Coach: JIMENEZ

REMARKS CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL - MALOCLUSSION xt
 F - TOOTH INDICATED FLU - FLUOROSIS Am
FOR FILLING Gn - NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
0 (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

District Meet Remarks/Findings:

MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
MACAMAY WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A

If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________

List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal

Pulse/Blood pressure(record) Normal Abnormal

Cardio Vascular System
NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM

Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?

Name of Athlete: , Fit to Play Not Fit to Pla

Signature Overprinted Name of Parent: 0 0

District Meet Date Examined: Regional Meet Date Examined:

0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined

0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
SARANGANI
Division
0
School
0
School Address

E CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

 This is to certify that ,
has
his date. the Grade/Year 0 (Elementary/Secondary Level) for the School Year

0
School Head/R
(Signature Over Pr

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 06/09/2019
Date

of my/our son/daughter
in all School Sports Meets

from his/her participation in

erved to ensure his/her health

ollect, process, retain, and dispose

a Privacy Act of 2012.

0
other Over Printed Name

0
School Head/Registrar
Signature Over Printed Name)
6/09/2019
DATE

MANENT TEETH

MENT NEEDS

SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
 - AMALGAM FILLING
- COMPOSITE FILLING

ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REFERRED FOR DENTAL TREATMENT:

YES NO

REMARKS
(FOR ANY ABNORMALITIES)
 REMARKS BY PARENT

Not Fit to Play

xamined:

0
n/Medical Officer
PTR #
te Examined:

n/Medical Officer
PTR #
 has completed

chool Year 2019-2020

0
ool Head/Registrar
re Over Printed Name)