Republic of the Philippines

DEPARTMENT OF EDUCATION
X
(Region)
Lanao del Norte
(Division)
ST. FRANCIS XAVIER ACADEMY OF KAPATAGAN, INC.
(School)
Poblacion, Kapatagan, Lanao del Norte
(School Address)

MEDICAL CERTIFICATE

(Date)

To Whom It May Concern:

This is to certify that I have personally examined ____________________________________

Name
age ______ sex _______ born on ____________________ and have found that he/she is physically fit during
the time of examination, to join and compete in the lower meets and Palarong Pambansa.

Event: _____________________________________

Physical Examination

Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:

Other Findings Yes No If Yes, Pls. specify

Asthma
Food Allergy
Undergone
Operation
Kidney Infection
Heart Ailment
Others

____________________________
Physician/Medical Officer
(Signature over printed name)
License No. __________________
PTR.: ____________________
Date: ____________________

FOR PALARONG PAMBANSA ONLY jmf_17