Revised as of September 26, 2019

Republic of the Philippines

MCForm - 1

DEPARTMENT OF EDUCATION

____________I____________

M E D I C A L C(REGION)
ERTIFICATE

To Whom It May Concern: School/Intrams/District Meet Remarks/Findings: FIT

UNFIT
This is to certify that I have personally examined __________________________________________________
_____________________________ Physician/Medical Officer Ht ._______cm Wt:_______kg Date:
Name
___________ age ___ sex ___ and have found that he/she is physically fit unfit, during the time of (signature over printed name) BP.____________mmHg

PRC PR:____________bpm
examination, to join and participate in the lower meets up to Palarong Pambansa.
LICENSE: PTR NO. RR:____________cpm
Event: VOLLEYBALL-GIRLS

Physical Examination Unit/Division Meet Remarks/Findings: FIT

School/Intrams/District Meet Unit/Division Meet Regional Meet Palarong Pambansa UNFIT

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

Normal Normal Normal Normal
(signature over printed name) BP.____________mmHg
1. Eyes YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm

2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm

3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO

Regional Meet Remarks/Findings: FIT
4. Neck YES | NO YES | NO YES | NO YES | NO
UNFIT
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO _____________________________Physician/Medical Officer Ht ._______cm Wt:_______kg Date:

6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg

PRC PR:____________bpm
7. Abdomen YES | NO YES | NO YES | NO YES | NO
LICENSE: PTR NO. RR:____________cpm
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 Palarong Pambansa Remarks/Findings: FIT

UNFIT
b. spine YES | NO YES | NO YES | NO YES | NO
_____________________________ Physician/Medical Officer Ht ._______cm Wt:_______kg Date:
c. shoulder YES | NO YES | NO YES | NO YES | NO
(signature over printed name) BP.____________mmHg

d. arms/hands YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm

LICENSE: PTR NO. RR:____________cpm

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 (reflexes) YES | NO YES | NO YES | NO YES | NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)