Republic of the Philippines

Department of Education
Region III
Schools Division of Nueva Ecija
Brgy. Rizal, Santa Rosa, Nueva Ecija

MEDICAL CERTIFICATE
FOR WORK IMMERSION

INSTRUCTION
The medical certificate should be accomplished by a licensed physician.

FOR THE LEARNER

School: Rizal National High School Strand: ______ Grade Level: _____ Section:________________

NAME (Last Name, First Name, Middle Name)

ADDRESS:

AGE: SEX: CIVIL STATUS:

FOR THE PHYSICIAN

Please check your medical history if applicable:

( ) Hypertension ( ) Allergy: ___________________________________
( ) Diabetes Mellitus ( ) Others: ___________________________________
( ) Heart Disease ( ) Last hospitalization: _____________________________
( ) Hepatitis B ( ) Surgical Operation :
_____________________________
( ) Pulmonary Tuberculosis LMP: _______________
( ) Anemia AOG: _______________
( ) Blurring of Vision EDC: _______________

I hereby certify that I have personally examined the above named individual and found him/her to be
physically and mentally fit/ unfit for work immersion.
NOTE / REMARKS: VITAL SIGNS:

BP: ______________mmHg

PR: _________ bpm RR: _________bpm

PRINTED NAME/ SIGNATURE OF PHYSICIAN: HEIGHT WEIGHT

________ cm ________ kg
OFFICIAL DESIGNATION: LICENSE NUMBER: DATE EXAMINED: