Republic of the Philippines MCForm - 1

Revised as of September 26, 2019

DEPARTMENT OF
EDUCATION III – CENTRAL
LUZON (REGION)

(DIVISION)

(SCHOOL)

(School Address)

MEDICAL CERTIFICATE

g. knees YES | NO YES | NO YES | NO YES | NO

To Whom It May Concern: h. ankles YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined i. feet YES | NO YES | NO YES | NO YES | NO
Name 11. Neuromuscular (reflexes) YES | NO YES | NO YES | NO YES | NO
age sex and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to
School/Intrams/District Meet Remarks/Findings:
Palarong Pambansa.
Ht . cm Wt: kg FIT
Physician/Medical Officer BP. mmHg
(signature over printed name) PR: bpm UNFIT
Event: PRC RR: cpm
LICENSE: PTR NO. Date:
Physical Examination
Unit/Division Meet Remarks/Findings:

School/Intrams/ Unit/Division Regional Meet Palarong Ph Ht . cm Wt: kg FIT

District Meet Meet Pambansa y sician/Medical Officer BP. mmHg
Normal Normal Normal Normal (signature over printed name) PR: bpm UNFIT
PRC RR: cpm
1. Eyes YES | NO YES | NO YES | NO YES | NO
LICENSE: PTR NO. Date:
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO
Regional Meet Remarks/Findings:
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO
4. Neck YES | NO YES | NO YES | NO YES | NO Phy Ht . cm Wt: kg FIT
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO sician/Medical Officer BP. mmHg
(signature over printed name) PR: bpm UNFIT
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO
PRC RR: cpm
7. Abdomen YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. Date:
8. Skin YES | NO YES | NO YES | NO YES | NO
Palarong Pambansa Remarks/Findings:
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO Ht . cm Wt: kg FIT
a. neck YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer BP. mmHg
(signature over printed name) PR: bpm UNFIT
b. spine YES | NO YES | NO YES | NO YES | NO PRC RR: cpm
c. shoulder YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. Date:
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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)