REPUBLIC OF THE PHILIPPINES

Province Of Kalinga
City of Tabuk
RHU-1

MEDICAL CERTIFICATE

__________________
Date

To whom it may concern:

This is to certify that I have personally examined ________________________________________ age _______

Sex ______ born on _______________________ and have found that she/he is physically fit to do work immersion.

Physical Examination

Date examined: _______________

Height: _________________ Weight : ___________________ Blood Pressure: _________________
Pulse Rate: ______________ Temperature:_____________________
Other remarks:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
______________________________________________________________________________________

MA. DIANA FALGUI-DALSEN, MD

License No.: 87127

REPUBLIC OF THE PHILIPPINES

Province Of Kalinga
City of Tabuk
RHU-1

MEDICAL CERTIFICATE

__________________
Date

To whom it may concern:

This is to certify that I have personally examined ________________________________________ age _______

Sex ______ born on _______________________ and have found that she/he is physically fit to do work immersion.

Physical Examination

Date examined: _______________

Height: _________________ Weight : ___________________ Blood Pressure: _________________
Pulse Rate: ______________ Temperature:_____________________
Other remarks:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____________________________________________________________________________________

MA. DIANA FALGUI-DALSEN, MD

License No.: 87127