Republic of the Philippines

DON HONORIO VENTURA TECHNOLOGICAL STATE UNIVERSITY

Bacolor, Pampanga

MEDICAL CERTIFICATION

Name:
SURNAME FIRST Middle

COURSE,YEAR & SECTION:

ADDRESS:
AGE:______ SEX: MALE CIVIL STATUS: SINGLE MARRIED WIDOWED
FEMALE
DATE OF PLACE OF BIRTH:
BIRTH:
HEIGHT (METERS): HEART RATE (at rest):
WEIGHT BLOOD PRESSURE (at
(KILOGRAM): rest):

PHYSICAL SIGNS DISORDER OF:

Yes No Yes No

*Heart *Mammary Gland

*Vascular system *Endocrine Gland
*Lungs *Locomotor Organ
*Liver *Lymph Gland
*Spleen *Genital Organ

If Yes, give details Under Remarks:

Remarks:

Yes No Do you consider the student at present for his/her participation in:

Off campus procedure

On-the-Job Training
Field Trip/ Educational Trip
Others, Specify:

Arthur L. Odchigue, MD,CSP

Univesity Physician

Date