2020 Medical Certificatr Combative 2

AR-I (ATHLETE RECORD)
Region
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name:
(Last) (First) (M.I.)
Sex: Learner Reference Number (LRN) Tel. No:
Date of Birth: (mm/dd/yy) Age: Place of Birth:
School:
Address of School:
Home Address:
Parents:
Fathers Name Mother/Guardian
Address of Parents:
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
(Use separate sheet if necessary)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

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e
Republic of the Philippines
Department of Education
_______________________
(Region)
_________________________
(Division)
______________________________
(School)
___________________________________
(School Address)
CERTIFICATE OF COMPLETION
Date:
To Whom It May Concern:
This is to certify that has completed

the Grade (Elementary/Secondary Level) for the School Year .
Principal/School Head/Registrar
(Signature over printed name)

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DEPARTMENT OF EDUCATION
Region
Division
DENTAL HEALTH RECORD Latest 1½ x 1½ picture

Name:
Age: Sex Birth Date Date
Event:
Parent/Guardian:
Coach:
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETH
DECIDOUS TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION
DATE OF VISIT
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 TEMPORARY 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 FOR ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST
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________________________
(Region)
___________________
(Division)
____________________________________
(School)
_____________________________________________
(School Address)
P A R E N TA L C O N S E N T
Date:
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter in the
Division, Regional Meet and 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 precautio n 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:

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___________________________
(Region)
________________________
(Division)
____________________________________
(School)
_______________________________________________
( School Address )
M E D I CAL C E R T I FI CAT E
Date:
To Whom It May Concern:
This is to certify that I have personally examined

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:
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medical Officer
License No.
PTR.:
Date:

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_______________________
(Region)
_____________________
(Division)
_____________________________________
(School)
__________________________________________
(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 NO
2. Have you ever been unconscious or had a concussion?YES NO YES NO
3. Have you been hit hard in the head in the last 6 weeksYES NO YES NO
4. Have you had any headache in the last 2 weeks? YES NO YES NO
5. Do you have any problem in bleeding? YES NO YES NO
6. Does any disease run in your family ? Sudden unexpec YES NO YES NO
7. Have you had any surgery? YES NO YES NO
8. Have you ever had to stay in a hospital? YES NO YES NO
9. Do you have any medical condition? YES NO YES NO
______________________________
Name and signature (Parent)
______________________________
Physician/Medical Officer
License No.
PTR.:
Date:
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_____________________
(Region)
______________________
(Division)
_____________________________
(School)
_______________________________
(School Address)
MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
If Athlete had a Concussion in the
period after Concussion was Normal Abnormal
past year please certify that:
normal Athlete Fit to Box
List abnormalities not covered in

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

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)
Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib tenderness on

Chest Normal Abnormal
compession
Pulse/ blood pressure (record) Normal Abnormal
Cardio Vascular System

Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm
Upper limb: shoulder wrist, hand,

Orthopedic System Normal Abnormal
fingers
Lower limb: (ankle, knee, hip 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
Fit to Play Not Fit to Play
Name of Athlete:
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
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________________
REGION
_______________________
DIVISION
_______________________________________
EVENT
CERTIFICATE OF EMPLOYMENT
APPOINTMENT/ CONTRACT OF
SERVICE
AFFIDAVIT / SWORN STATEMENT

PERSONAL DATA SHEET
Coach
MEDICAL CERTIFICATE
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION
NAME
SCHOOL
AR - 1
PHOTOCOPY OF NSO
NSO
FORM - 137
CERTIFICATE OF ENROLMENT
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
AR - 1
PHOTOCOPY OF NSO
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
AR - 1
PHOTOCOPY OF NSO
NSO
FORM - 137
athlete
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
_______
Assistant Coach/Chaperon
athlete
athlete
athlete
athlete
____________________________
REGION
______________________________
DIVISION
__________________________________
EVENT
AR - 1
PHOTOCOPY OF NSO
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
AR - 1
PHOTOCOPY OF NSO
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
AR - 1
PHOTOCOPY OF NSO
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
AR - 1
PHOTOCOPY OF NSO
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
athlete
athlete
athlete
athlete

2020 Medical Certificatr Combative 2

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2020 Medical Certificatr Combative 2

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AR-I (ATHLETE RECORD)

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

(Use separate sheet if necessary)

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that has completed

FOR PALARONG PAMBANSA ONLY

DENTAL HEALTH RECORD Latest 1½ x 1½ picture

Signature of Father Signature of Mother

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that I have personally examined

age sex born on and have found that he/she is

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

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

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

7. Have you had any surgery? YES NO YES NO

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

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

MEDICAL CERTIFICATE ABNORMALITIE

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Breath sounds, rib tenderness on

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Fit to Play Not Fit to Play

AFFIDAVIT / SWORN STATEMENT

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