Revised as of September 26,

2019

MEDICAL CERTIFICATE
b. spine YES | NO YES | NO YES | NO YES | NO
To Whom It May Concern: c. shoulder YES | NO YES | NO YES | NO YES | NO
d. arms/hands YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined LUZ , DAXX RAVEN L. age e. hips YES | NO YES | NO YES | NO YES | NO
Name
11 sex Male and have found that he/she is physically fit unfit, during the f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
time of examination, to join and participate in the lower meets up to Palarong
h. ankles YES | NO YES | NO YES | NO YES | NO
Pambansa. i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
(reflexes)
Event: Badminton (Boys) Elementary

Physical Examination School/Intrams/District Meet Remarks/Findings:

School/ Unit/Division Regional Palarong _____________________________ Ht ._______cm FIT

Intrams/District Meet Meet Pambansa Physician/Medical Officer Wt:_______kg
Meet (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
Normal Normal Normal Normal LICENSE: PTR NO. RR:____________cpm Date:
1. Eyes YES | NO YES | NO YES | NO YES | NO Unit/Division Meet/Provincial Meet Remarks/Findings:
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
4. Neck YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Regional Meet Remarks/Findings:

_____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Palarong Pambansa Remarks/Findings:

_____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)