Revised as of April 3, 2023 Republic of the Philippines

Department of Education
___________________________
(Region)
_____________________________
(Division)
____________________________________
(School)
_______________________________________________

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

_______________________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined ____________________________ age ______ sex _____
Name
and have found that he/she is physically fit unfit, during the time of examination, to join and participate in

the lower meets up to Palarong Pambansa.

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

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
UNFIT
(signature over printed name) PR:____________bpm
PRC Date:
RR:____________cpm
LICENSE: PTR NO.
Unit/Division Meet Remarks/Findings:
Ht ._______cm Wt:_______kg
________________________________________ FIT
BP.____________mmHg
Physician/Medical Officer
PR:____________bpm UNFIT
(signature over printed name)
PRC RR:____________cpm Date:
LICENSE: PTR NO.
Regional Meet Remarks/Findings:
Ht ._______cm Wt:_______kg
________________________________________ FIT
BP.____________mmHg
Physician/Medical Officer
(signature over printed name) PR:____________bpm
UNFIT
PRC RR:____________cpm
LICENSE: PTR NO. Date:
Palarong Pambansa Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

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

Note:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to PALARONG PAMBANSA)