Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

___________XII_____________
(REGION)
_________COTABATO___________
(DIVISION)
__DILANGALEN NATIONAL HIGH SCHOOL_
(SCHOOL)
__POBLACION 1,,MIDSAYAP,COTABATO

(School Address)

M E D I CAL C E R T I FI CAT E

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
___________XII_____________
(REGION)
_________COTABATO___________
i. feet | NO(DIVISION) NATIONAL
YES__DILANGALEN HIGH SCHOOL_
To Whom It May Concern: 11. Neuromuscular YES | NO(SCHOOL)
__POBLACION 1,,MIDSAYAP,COTABATO
(reflexes)
This is to certify that I have Name (School Address)

personally examined BUCO ,

School/Intrams/District Meet Remarks/Findings:
DESIREE F. age 15 sex FEMALE and
_____________________________ Ht ._______cm
have found that he/she is physically
Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg
fit unfit, during the time of PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
examination, to join and participate Remarks/Findings:
in the lower meets up to _____________________________
Palarong Ht ._______cm
Pambansa. Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg
PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Event: _BASKETBALL (GIRLS) Remarks/Findings:

_____________________________ Ht ._______cm
Physical Examination
Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg
School/Intrams/
PR:____________bpm
District Meet
LICENSE: PTR NO. RR:____________cpm Date:
Normal Remarks/Findings:
1. Eyes YES | NO
2. Ears, Nose, Throat _____________________________
YES | NO Ht ._______cm
Physician/Medical Officer Wt:_______kg
3. Mouth and Teeth YES | NO
(signature over printed name) BP.____________mmHg
4. Neck YES | NO PR:____________bpm
5. Cardiovascular LICENSE:YES | NO PTR NO. RR:____________cpm Date:
6. Chest and Lungs YES | NO
7. Abdomen YES | NO
8. Skin YES | NO
9. Genitalia-Hernia (male) YES | NO
10. Muskuloskeletal: ROM YES | NO
a. neck YES | NO
b. spine YES | NO
c. shoulder YES | NO
d. arms/hands YES | NO
e. hips YES | NO
f. thighs YES | NO
g. knees YES | NO
h. ankles YES | NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)