Republic of the

Revised as of September 26,

Philippines MCForm - 1

DEPARTMENT OF EDUCATION

___________02_____________

(REGION)

_____________ISABELA_________________

(DIVISION)

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 ___________________ age e. hips YES | NO YES | NO YES | NO YES | NO
Name
____ sex _____ and have found that he/she is physically fit unfit, during f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
the 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 (reflexes) YES | NO YES | NO YES | NO YES | NO

Event: ___________________________
Legislative District Meet Remarks/Findings:
Physical Examination _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
School/ Unit/Division Regional Palarong (signature over printed name) BP.____________mmHg
Intrams/District Meet Meet Pambansa UNFIT
PRC PR:____________bpm
Meet LICENSE: PTR NO. RR:____________cpm Date:
Normal Normal Normal Normal
Unit/Division Meet Remarks/Findings:
1. Eyes YES | NO YES | NO YES | NO YES | NO
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO
(signature over printed name) BP.____________mmHg UNFIT
4. Neck YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO Regional Meet Remarks/Findings:
7. Abdomen YES | NO YES | NO YES | NO YES | NO
_____________________________ Ht ._______cm
8. Skin YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
FIT
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm
a. neck YES | NO YES | NO YES | NO YES | NO Date:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the

Philippines MCForm - 1

DEPARTMENT OF EDUCATION

___________02_____________

Palarong Pambansa Remarks/Findings: (REGION)

_____________________________ Ht ._______cm _____________ISABELA_________________

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

UNFIT

Date:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)