Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

ZAMBOANGA PENINSULA
(REGION)
ZAMBOANGA DEL SUR
(DIVISION)
COMMONWEALTH ELEMENTARY SCHOOL
(SCHOOL)
COMMONWEALTH, AURORA ZDS
(School Address)

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
ZAMBOANGA PENINSULA
(REGION)
ZAMBOANGA DEL SUR
(DIVISION)
To Whom It May Concern: COMMONWEALTH ELEMENTARY SCHOOL
(SCHOOL)
COMMONWEALTH, AURORA ZDS
This is to certify that I have personally examined JHOMAR B. VALLASO age 12(School
sex Address)
Name School/Intrams/District Meet Remarks/Findings:
MALE and have found that he/she is physically fit unfit, during the time of
_____________________________ Ht ._______cm FIT
examination, to join and participate in the lower meets up to Palarong Pambansa. Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
Event: ARNIS ELEMENTARY BOYS PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Physical Examination Unit/Division Meet Remarks/Findings:

School/ Unit/Division Regional Palarong _____________________________ Ht ._______cm FIT

Intrams/District Meet Meet Pambansa Physician/Medical Officer Wt:_______kg
Meet (signature over printed name) BP.____________mmHg UNFIT
Normal Normal Normal Normal PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
1. Eyes YES | NO YES | NO YES | NO YES | NO
Regional Meet Remarks/Findings:
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
4. Neck YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO
PRC PR:____________bpm
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
7. Abdomen YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings:
8. Skin YES | NO YES | NO YES | NO YES | NO
_____________________________ Ht ._______cm FIT
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
Physician/Medical Officer Wt:_______kg
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
a. neck YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
b. spine YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
c. shoulder YES | NO YES | NO YES | NO YES | NO
d. arms/hands YES | NO YES | NO YES | NO YES | NO
e. hips YES | NO YES | NO YES | NO YES | NO
f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
h. ankles YES | NO YES | NO YES | NO YES | NO
i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
(reflexes)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)