Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

REGION III – CENTRAL LUZON
(REGION)
SAN JOSE DEL MONTE CITY
(DIVISION)

SAN______________________________
ISIDRO ELEMENTARY
(SCHOOL) SCHOOL
______________________________
Provincial Rd. Brgy. San Isidro
(School Address)

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
REGION III – CENTRAL LUZON
(REGION)
SAN JOSE DEL MONTE CITY
(DIVISION)
School/Intrams/District Meet Remarks/Findings:
To Whom It May Concern: ______________________________
(SCHOOL) _____________________________ Ht ._______cm FIT
______________________________Physician/Medical Officer Wt:_______kg
This is to certify that I have personally examined Adrian Joseph D. Dela Cruz (signature over printed name) BP.____________mmHg UNFIT
Name (School Address)
PRC PR:____________bpm
age 12 sex MALE 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
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
Event: ATHLETICS LICENSE: PTR NO. RR:____________cpm Date:
Regional Meet Remarks/Findings:
Physical Examination
_____________________________ Ht ._______cm FIT
School/Intrams/ Unit/Division Regional Palarong Physician/Medical Officer Wt:_______kg
District Meet Meet Meet Pambansa (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
Normal Normal Normal Normal
LICENSE: PTR NO. RR:____________cpm Date:
1. Eyes YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings:
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
4. Neck YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
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)