Republic of the Philippines

Department of Education
Region III
SCHOOL DIVISION OFFICE OF BULACAN

MEDICAL CERTIFICATE OF ATHLETE

________________________________
Date

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 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: ( ) Asthma ( ) Mumps

( ) Measles ( ) Allergies
( ) Chickenpox

_______________________________
Medical Officer _______
License No.: ________
PTR: _____________
Date: ____________

FOR PALARONG PAMBANSA ONLY

QM - Page 1 of 3
 Medical Certificate for Contact Sports

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following past

If Athlete had a Concussion in the Normal Abnormal
period after Concussion was normal
past year please certify that:
Athlete Fit to Box

General Medical Exam List abnormalities not covered in

specific system exams below:
Medical Status/Psychological Normal Abnormal
Brief survey
Cranial nerves, eyes, pupil, size and Normal Abnormal
reactivity, Fundi, Vision by chart
Head (record)
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, lymph nodes Normal Abnormal
Breath sounds, rib Normal Abnormal
Chest
Tenderness on compression
Pulse/ blood pressure Normal Abnormal
(record)
Cardio Vascular System
Heart examination, sounds, Normal Abnormal
murmurs, heaves, size, rhythm
Upper limb: shoulder, wrist, hand, Normal Abnormal
Orthopedic System fingers
Lower limb: ankle, nee, 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
Any Therapeutic Use Exemption (TUE) Submitted? NO YES (if YES, Please explain)

Name of Athlete __________________________

____________________________
Medical Officer _____
Lic. Number: __________
Date:___________

FOR PALARONG PAMBANSA ONLY

QM - Page 2 of 3
 (Arnis, Boxing, Gymnastics, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PARENT MEDICAL 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 ever been hit hard in the head in the last 6 weeks?
__________________________________________________________ YES 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 unexpected death?

__________________________________________________________ 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 of Parent

_______________________________
Medical Officer ____

License No. __________

PTR :____________
Date:____________

FOR PALARONG PAMBANSA ONLY

QM - Page 3 of 3