Revised as of September 26, Republic of the Philippines MCForm - 1

2019 DEPARTMENT OF EDUCATION

IX, ZAMBOANGA PENINSULA
(REGION)

DIVISION OF ZAMBOANGA DEL SUR

(DIVISION)
______________________________

MEDICAL CERTIFICATE
e. hips YES | NO YES | NO YES | NO YES | NO
To Whom It May Concern: f. thighs YES | NO YES | NO YES | NO YES | NO
EPENITO C. CAHILOG 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
12 sex _____
age ____ FEMALE
and have found that he/she is physically fit i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
unfit, during the time of examination, to join and participate in the lower meets up to (reflexes)
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 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
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:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
IX, ZAMBOANGA PENINSULA
(REGION)

DIVISION OF ZAMBOANGA DEL SUR

(DIVISION)
______________________________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)