MEDICAL CERTIFICATE

d. arms/hands YES | NO YES | NO YES | NO YES | NO

To Whom It May Concern: e. hips YES | NO YES | NO YES | NO YES | NO
f. thighs YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined__EHRA MARIE g. knees YES | NO YES | NO YES | NO YES | NO
R.BORROMEO_, age 15 sex F__ and have found that he/she is physically fit h. ankles YES | NO YES | NO YES | NO YES | NO
unfit, during the time of examination, to join and participate in the lower i. feet YES | NO YES | NO YES | NO YES | NO
meets up to Palarong Pambansa. 11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
(reflexes)

Event: DANCESPORTS School/Intrams/District Meet Remarks/Findings:

Physical Examination __________________________ Ht ._______cm FIT

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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 (signature over printed name) BP.____________mmHg
PRC PR:____________bpm UNFIT
LICENSE: PTR NO. RR:____________cpm
Date:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)