Revised as of September 26, 2019

Republic of the Philippines

DEPARTMENT OF EDUCATION

III
(REGION)

ZAMBALES
(DIVISION)

NAGYANTOK HIGH SCHOOL

(SCHOOL)

CAWAG, SUBIC, ZAMBALES

M E D I C A L(School
C EAddress)
RTIFICATE

To Whom It May Concern: i. feet YES | NO YES | NO YES | NO YES | NO

11. Neuromuscular (reflexes) YES | NO YES | NO YES | NO YES | NO

This is to certify that I have personally examined JAMES JR. A. TAYA-AN
School/Intrams/District Meet Remarks/Findings: FIT

UNFIT
age 15 sex male and have found that he/she is physically fit unfit, during the time of examination, to join and participate in the lower
_____________________________ Physician/Medical Officer Ht ._______cm Wt:_______kg Date:

(signature over printed name) BP.____________mmHg

meets up to Palarong Pambansa.
PRC PR:____________bpm

LICENSE: PTR NO. RR:____________cpm

Unit/Division Meet Remarks/Findings: FIT

Event: WUSHU-SANDA
UNFIT

_____________________________Physician/Medical Officer Ht ._______cm Wt:_______kg Date:

Physical Examination
(signature over printed name) BP.____________mmHg

PRC PR:____________bpm
School/Intrams/District Meet Unit/Division Meet Regional Meet Palarong Pambansa
LICENSE: PTR NO. RR:____________cpm

Normal Normal Normal Normal

Regional Meet Remarks/Findings: FIT
1. Eyes YES | NO YES | NO YES | NO YES | NO
UNFIT
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO _____________________________Physician/Medical Officer Ht ._______cm Wt:_______kg Date:

3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg

PRC PR:____________bpm
4. Neck YES | NO YES | NO YES | NO YES | NO
LICENSE: PTR NO. RR:____________cpm
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO

6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings: FIT

7. Abdomen YES | NO YES | NO YES | NO YES | NO UNFIT

_____________________________ Physician/Medical Officer Ht ._______cm Wt:_______kg Date:

8. Skin YES | NO YES | NO YES | NO YES | NO
(signature over printed name) BP.____________mmHg
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
PRC PR:____________bpm
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm

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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)