Document Code No.

FM-SSCT-CLI-005

Revision No. 00

Effective Date 20 September 2018

Page No. 1 of 1

SURIGAO DEL NORTE

STATE UNIVERSITY

MEDICAL FITNESS CERTIFICATE

To whom so ever it may concern

This is to certify that I have seen and examined Mr./Miss ___________________________.

_____________________________ student of this College.

Vital Signs:

Blood Pressure: ____________mmHg HR:___ bpm RR:___ cpm Temp: _______

Height: __________ Weight: __________

He/she is suffering /not suffering from following diseases:

Asthma Diabetes Cardiovascular Disease Allergy Kidney Disorders

Pulmonary Tuberculosis Convulsions Physical Disability Mental Disability

Any other major disease (Please specify):

I certify that Mr./Miss ____________________________________ is physically, mentally, and psychologically fit/unfit for

____________________________________________________.

_____________ ____________

College Physician

Lic. No. ____________