Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

________________________
(REGION)
______________________________
(DIVISION)
______________________________
(SCHOOL)
______________________________

(School Address)

M E D I CAL C E RT I FI CAT E

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
________________________
(REGION)
______________________________
(DIVISION)
d. arms/hands
______________________________
YES | NO YES | YES | YES |
To Whom It May Concern: (SCHOOL) NO NO NO
______________________________
e. hips YES | NO YES | YES | YES |
This is to certify that I have personally examined ___________________
Name (School Address) NO NO NO
age ____ sex _____ and have found that he/she is physically fit unfit, f. thighs YES | NO YES | YES | YES |
NO NO NO
during the time of examination, to join and participate in the lower meets up to g. knees YES | NO YES | YES | YES |
Palarong Pambansa. NO NO NO
h. ankles YES | NO YES | YES | YES |
NO NO NO
Event: ___________________________ i. feet YES | NO YES | YES | YES |
NO NO NO
Physical Examination 11. Neuromuscular YES | NO YES | YES | YES |
(reflexes) NO NO NO
School/Intrams/ Unit/Division Regional Palarong
District Meet Meet Meet Pambansa
Normal Normal Normal Normal School/Intrams/District Meet Remarks/Findings:
1. Eyes YES | NO YES | YES | YES |
_____________________________ Ht ._______cm FIT
NO NO NO Physician/Medical Officer Wt:_______kg
2. Ears, Nose, Throat YES | NO YES | YES | YES | (signature over printed name) BP.____________mmHg UNFIT
NO NO NO PRC PR:____________bpm
3. Mouth and Teeth YES | NO YES | YES | YES | LICENSE: PTR RR:____________cpm Date:
NO.
NO NO NO Unit/Division Meet Remarks/Findings:
4. Neck YES | NO YES | YES | YES |
NO NO NO _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
5. Cardiovascular YES | NO YES | YES | YES | (signature over printed name) BP.____________mmHg UNFIT
NO NO NO PRC PR:____________bpm
6. Chest and Lungs YES | NO YES | YES | YES | LICENSE: PTR RR:____________cpm Date:
NO NO NO NO.
Regional Meet Remarks/Findings:
7. Abdomen YES | NO YES | YES | YES |
NO NO NO _____________________________ Ht ._______cm FIT
8. Skin YES | NO YES | YES | YES | Physician/Medical Officer Wt:_______kg
NO NO NO (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
9. Genitalia-Hernia (male) YES | NO YES | YES | YES | LICENSE: PTR RR:____________cpm Date:
NO NO NO NO.
10. Muskuloskeletal: YES | NO YES | YES | YES | Palarong Pambansa Remarks/Findings:
ROM NO NO NO _____________________________ Ht ._______cm FIT
a. neck YES | NO YES | YES | YES | Physician/Medical Officer Wt:_______kg
NO NO NO (signature over printed name) BP.____________mmHg UNFIT
b. spine YES | NO YES | YES | YES | PRC PR:____________bpm
LICENSE: PTR RR:____________cpm Date:
NO NO NO NO.
c. shoulder YES | NO YES | YES | YES |
NO NO NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)