MCForm – 1

Revised as of September 26,

2019 Republic of the Philippines
Department of Education
Region VII, Central Visayas
Division of City School City of Naga
CANTAO- AN NATIONAL HIGH SCHOOL
Cantao- an, City of Naga, Cebu

MEDICAL CERTIFICATE
g. knees YES | NO YES | NO YES | NO YES | NO
To Whom It May Concern: h. ankles YES | NO YES | NO YES | NO YES | NO
Name i. feet YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined ___________________ age 11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
____ sex _____ and have found that he/she is physically fit unfit, during (reflexes)

the time of examination, to join and participate in the lower meets up to Palarong
School/Intrams/District Meet Remarks/Findings:
Pambansa.
Event: ___________________________ _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg
Physical Examination PRC PR:____________bpm
UNFIT
LICENSE: PTR NO. RR:____________cpm Date:
School/ Unit/Division Regional Palarong
Intrams/District Meet Meet Pambansa Unit/Division Meet Remarks/Findings:
Meet
_____________________________ Ht ._______cm
Normal Normal Normal Normal Physician/Medical Officer Wt:_______kg
FIT
1. Eyes YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO Date:
Regional Meet Remarks/Findings:
4. Neck YES | NO YES | NO YES | NO YES | NO
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
7. Abdomen YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
8. Skin YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings:
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO
a. neck YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
b. spine YES | NO YES | NO YES | NO YES | NO
(signature over printed name) BP.____________mmHg UNFIT
c. shoulder YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
d. arms/hands YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
e. hips YES | NO YES | NO YES | NO YES | NO
f. thighs YES | NO YES | NO YES | NO YES | NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)