REPUBLIC OF THE PHILIPPINES

PROVINCE OF CAVITE
CITY OF DASMARIÑAS
OFFICE OF THE CITY HEALTH OFFICER
City Health Office I

_______________
Date

MEDICAL CERTIFICATE
TO WHOM IT MAY CONCERN:

This is to certify that BONIFACIO S. FURIGAY had undergone

Physical Examination in Main Health Center and found him/her to be
physically fit to participate in his/her event.
VITAL SIGNS:
HP: ______mmHg RR: ______bpm

TEMP:_______ C PR:______bpm
HEAD:
EYE…………………… WT:______kg.
EAR…………………..
NOSE……………….. HT:______cm.

CHEST………………………….
LUNGS…………………………
ABDOMEN…………………..
EXTREMITIES………………..

REMARKS: Essentially Normal Finding

RECOMMENDATION: FIT TO PLAY_______________________

NOT VALID FOR MEDICO-LEGAL PURPOSES

________________________
Physician/Medical Officer
(Signature over printed name)
License No.___________
PTR:_________________
Date:_____________