Revised as of September 26, 2019 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
III
(REGION)
SCIENCE CITY OF MUNOZ
(DIVISION)
SAN FELIPE ELEMENTARY SCHOOL
(SCHOOL)
BARANGAY SAN FELIPE, SCIENCE CITY OF MUNOZ
(School Address)

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
III
(REGION)
School/Intrams/District
SCIENCE CITY OF MUNOZ Meet Remarks/Findings:
(DIVISION)
To Whom It May Concern: SAN FELIPE ELEMENTARY SCHOOL
_____________________________ Ht ._______cm
(SCHOOL) FIT
Physician/Medical Officer Wt:_______kg
This is to certify that I have personally examined _____________________
BARANGAY SAN FELIPE, SCIENCE CITY OF MUNOZ
(signature over printed name) BP.____________mmHg
Name (School Address) UNFIT
PRC PR:____________bpm
age ____ sex _____ and have found that he/she is physically fit unfit, LICENSE: PTR NO. RR:____________cpm Date:
during the time of examination, to join and participate in the lower meets up to Unit/Division Meet Remarks/Findings:

Palarong Pambansa. _____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
MARRIANE C. CORONEL, MD (signature over printed name) BP.____________mmHg UNFIT
Medical Officer III PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Event: ___________________________ Regional 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 Palarong Pambansa Remarks/Findings:
1. Eyes YES | NO YES | NO YES | NO YES | NO
_____________________________ Ht ._______cm
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
FIT
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
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO Date:
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO
7. Abdomen YES | NO YES | NO YES | NO YES | NO
8. Skin YES | NO YES | NO YES | NO YES | NO
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO
a. neck YES | NO YES | NO YES | NO YES | NO
b. spine YES | NO YES | NO YES | NO YES | NO
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)