Revised as of September 26, 2019 DEPARTMENT OF EDUCATION
____________IV-A____________ (REGION) ________________RIZAL______________ (DIVISION) ___________ ACLC COLLEGE TAYTAY____________ (SCHOOL) ___________ SAN JUAN, TAYTAY, RIZAL___________________ (School Address)
MEDICAL CERTIFICATE
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines MCForm - 1 DEPARTMENT OF EDUCATION ____________IV-A____________ (REGION) ________________RIZAL______________ (DIVISION) School/Intrams/District Meet Remarks/Findings: To Whom It May Concern: ___________ ACLC COLLEGE TAYTAY____________ (SCHOOL) _____________________________ Ht ._______cm FIT ___________ Physician/Medical Officer SAN JUAN, TAYTAY, RIZAL___________________ Wt:_______kg This is to certify that I have personally examined _____________________ (School Address) (signature over printed name) BP.____________mmHg UNFIT Name PRC PR:____________bpm __________________________age ____ sex _____ and have found that he/she is LICENSE: PTR NO. RR:____________cpm Date: physically fit unfit, during the time of examination, to join and Unit/Division Meet Remarks/Findings:
participate in the lower meets up to Palarong Pambansa. _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg (signature over printed name) BP.____________mmHg UNFIT PRC PR:____________bpm Event: ACLC Collega Taytay’s Interblock Sportsfest 2023 LICENSE: PTR NO. RR:____________cpm Date: Regional Meet Remarks/Findings: Physical Examination _____________________________ Ht ._______cm FIT School/ Unit/Division Regional Palarong Physician/Medical Officer Wt:_______kg Intrams/District Meet Meet Pambansa (signature over printed name) BP.____________mmHg UNFIT Meet PRC PR:____________bpm LICENSE: PTR NO. RR:____________cpm Date: Normal Normal Normal Normal Palarong Pambansa Remarks/Findings: 1. Eyes YES | NO YES | NO YES | NO YES | NO 2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT 3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg (signature over printed name) BP.____________mmHg UNFIT 4. Neck YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm 5. Cardiovascular YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm 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)