Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

2
(REGION)
DIVISION OF NUEVA VIZCAYA
(DIVISION)
_________________________________________
(SCHOOL)
_________________________________________
(School Address)

MEDICALCERTIFICATE

FOR SCHOOL SPORTS

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
2
(REGION)
DIVISION OF NUEVA VIZCAYA
(DIVISION)
School/Intrams/District Meet Remarks/Findings:
To Whom It May Concern: _________________________________________
(SCHOOL) _____________________________ Ht ._______cm FIT
Physician/Medical Officer
_________________________________________ Wt:_______kg
This is to certify that I have personally examined ______________ age ___ (School Address) (signature over printed name) BP.____________mmHg UNFIT
Name
PRC PR:____________bpm
sex ______ and have found that he/she is physically fit unfit, during LICENSE: PTR NO. RR:____________cpm Date:
the time of examination, to join and participate in the lower meets up to Regional Unit/Division Meet Remarks/Findings:

Invitational Sporting Events( DepEd DOS RISE). _____________________________ Ht ._______cm FIT

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

FOR SCHOOL SPORTS