Athletes e Forms

Republic of the Philippines
Department of Education
Region VII
TAGBILARAN CITY
Name of School
(School)
CERTIFICATE OF ENROLMENT
Date:
To Whom It May Concern:
This is to certify that has been enrolled
for the School Year 2019 - 2020 .
School Head / Registrar

(Signature over printed name)
Region VII
TAGBILARAN CITY
Name of School
(School)
CERTIFICATE OF COMPLETION
Date:
This is to certify that has been enrolled
for the School Year 2019-2020 and has actually completed said school year.
School Head / Registrar

Region VII
TAGBILARAN CITY
Name of School
(School)
P A R E N TA L C O N S E N T
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter in the Lower Meets up to
the Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precaution will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Signature of Father Signature of Mother
Name of Father Name of Mother
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by:
Teacher-Adviser/School Head/Registrar
Remarks:
#REF!
Region VII
Division of TAGBILARAN
Name of School
(School)
M E D I CAL C E R T I FI CAT E
(Date)
This is to certify that I have personally exami

Name
age sex born on , and have found that he/she is
physically fit, during the time of examination, to join and compete in the Lower Meets and
Palarong Pambansa.
Event: Picture
Physical Examination
Date examined:
Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:
Physician/Medical Officer
License No. :
PTR.:
Date:
DEPARTMENT OF EDUCATION
VII
Region
Tagbilaran City
Division
DENTAL HEALTH RECORD

Name:
Age: Sex Birth Date , Date
Event:
Parent/Guardian:
Coach:
GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
YEAR LEVEL REMARKS TEMPORARY TEETH

DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FO

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
HEAVY
SHADE FILLING (1-2 QUADRANTS) ARTIFIC
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
(√) - SOUND ERUPTED PERMANENT ZOE
TOOTH TF
R
UN
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST
ON
ORD
Date
PERIODONTAL
DISEASE
MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CLEFT PALATE
ROOT FRAGMENT
OTHERS (Specify)
DATE OF VISIT
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
PERMANENT TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
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
VII
(Region)
TAGBILARAN CITY
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES
2. Have you ever been unconscious or had a concussion?YES NO YES
3. Have you been hit hard in the head in the last 6 weeksYES NO YES
4. Have you had any headache in the last 2 week? YES NO YES
5. Do you have any problem in bleeding? YES NO YES
6. Does any disease run in your family ? Sudden unexfec YES NO YES
7. Have you had any surgery? YES NO YES
8. Have you ever had to stay in a hospital? YES NO YES
9. Do you have any medical dondition? YES NO YES
0
Name and signature (Parent or Guardian)
Physician/Medical Officer
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY

MEDICA
L
OFFICER
NO
NO
NO
NO
NO
NO
NO
NO
NO
VII
(Region)
TAGBILARAN CITY
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW)
DATE OF EXAMINATION: _________________________________
If Athlete had a Concussion in the Medical Examination following post

past year. period after Concussion was Normal Abnormal
normal.
Please note if any:
____________________________
List of abnormalities not covered in

General Medical Exam specific system exams below:
Mental Status/ Psychological Brief survey
Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)
(a) Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib
(c) Chest Normal Abnormal
tenderness on compession
Pulse/ blood pressure
Normal Abnormal
(record)
(d) Cardio Vascular System
Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm
Upper limb: shoulder wrist, hand,

Normal Abnormal
(e) Orthopedic System fingers
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal
(f) Neurological System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No
Name of Athlete:
Fit to Play
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY

REMARKS
(FOR ANY
ABNORMALITIE
S)
Not Fit to Play
__________________________________
mber:______________________
Date:______________________

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Athletes e Forms

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Republic of the Philippines

To Whom It May Concern:

This is to certify that has been enrolled

for the School Year 2019 - 2020 .

School Head / Registrar

To Whom It May Concern:

This is to certify that has been enrolled

School Head / Registrar

Signature of Father Signature of Mother

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

To Whom It May Concern:

This is to certify that I have personally exami

Height: Weight: Blood Pressure:

DENTAL HEALTH RECORD

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FO

Division Meet Remarks/Findings:

SYMBOLS FOR ACCOMPLISHMENT

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

2. Have you ever been unconscious or had a concussion?YES NO YES

5. Do you have any problem in bleeding? YES NO YES

7. Have you had any surgery? YES NO YES

8. Have you ever had to stay in a hospital? YES NO YES

9. Do you have any medical dondition? YES NO YES

FOR PALARONG PAMBANSA ONLY

If Athlete had a Concussion in the Medical Examination following post

List of abnormalities not covered in

Mental Status/ Psychological Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip) Normal Abnormal

FOR PALARONG PAMBANSA ONLY

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