Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
VIII – EASTERN VISAYAS
(REGION)
SOUTHERN LEYTE
(DIVISION)
__________________________________________
(SCHOOL)
__________________________________________
(School Address)

MEDICAL CERTIFICATE
To Whom It May Concern: f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined h. ankles YES | NO YES | NO YES | NO YES | NO
Name
______________________________ age ____ sex _____ and have found that he/she is i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
physically fit unfit, during the time of examination, to join and participate in the
(reflexes)
lower meets up to Palarong Pambansa.

School/Intrams/District Meet Remarks/Findings:

Event: ___________________________ _____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
Physical Examination (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
School/ Unit/Division Regional Palarong LICENSE: PTR NO. RR:____________cpm Date:
Intrams/District Meet Meet Pambansa Unit/Division Meet Remarks/Findings:
Meet
Normal Normal Normal Normal _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
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
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
4. Neck YES | NO YES | NO YES | NO YES | NO Regional Meet Remarks/Findings:
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO
_____________________________ Ht ._______cm
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
FIT
7. Abdomen YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
8. Skin YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO Date:
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings:
a. neck YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
b. spine YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
c. shoulder YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
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
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
VIII – EASTERN VISAYAS
(REGION)
SOUTHERN LEYTE
(DIVISION)
__________________________________________
(SCHOOL)
__________________________________________
(School Address)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)