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Republic of the Philippines

DEPARTMENT OF EDUCATION
Region VI-Western Visayas
Division of San Carlos City
JULIO LEDESMA NATIONAL HIGH SCHOOL
J. V. Ledesma Avenue, Barangay Palampas, San Carlos City, Negros Occidental

MEDICAL CERTFICATE

Date: ____________________

To Whom It May Concern:

This is to certify that I have personally examined ________________________________,


age ______, sex ____________, born on ___________ and have found that he/she is
physically fit during the time of examination to the work immersion.

Physical Examination
Date examined : __________________________
Height : ________ Weight : _________ Blood Pressure : _________
Pulse, Resting : ________ Respiratory Rate : _______________
Other Remarks : _______________________________________________________

Other Findings Yes No If Yes, please specify


Asthma
Food Allergy
Undergone Operation
Kidney Infection
Heart Ailment
Others

This certification is issued upon the request of the above – mentioned name for
whatever legal purpose it may serve him/her best.

______________________________
Medical Officer
For Work Immersion Only

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