Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

BICOL - V
MASBATE PROVINCE
BATUAN DISTRICT
BATUAN CENTRAL SCHOOL
Poblacion, Batuan, Masbate

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
BICOL - V
MASBATE PROVINCE
BATUAN DISTRICT
BATUAN CENTRAL SCHOOL
To Whom It May Concern: Poblacion, Batuan, Masbate
School/Intrams/District Meet Remarks/Findings:
This is to certify that I have personally examined ___________________
Name _____________________________ Ht ._______cm FIT
14
age ____ sexFEMALE
_____ and have found that he/she is physically fit unfit, Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
during the time of examination, to join and participate in the lower meets up to PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Palarong Pambansa. Unit/Division Meet Remarks/Findings:

_____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
Event: FUTSAL (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
Physical Examination LICENSE: PTR NO. RR:____________cpm Date:
Regional Meet Remarks/Findings:
School/ Unit/Division Regional Palarong
Intrams/District Meet Meet Pambansa _____________________________ Ht ._______cm FIT
Meet Physician/Medical Officer Wt:_______kg
Normal Normal Normal Normal (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
1. Eyes YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings:
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO
4. Neck YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
7. Abdomen YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
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
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
i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
(reflexes)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)