Medical Certificate

Name of Student: Elizabeth Kate C. Arabiana Age: 18

Gender: Female Grade: HUMSS 11 Y1-1 Contact: +639954110567
Address: Blk 47 L9 LBEH, Calamba, Laguna
Parents or Guardian’s Name: Elisa C. Arabiana
Contact: +639171079473 Address: Blk 47 L9 LBEH, Calamba, Laguna
A. Medical History
Yes No Have you suffered at any time of the following?
Ear problems: earache, discharge, or deafness
Pulmonary disease, including asthma, bronchitis,
collapsed lung, or T.B infections
Heart disease
Nervous disorders including persistent headache
Anxiety problems
Are you currently being treated for an injury or
illness?
Do you have an eye problem not correctable by
glasses or contacts?
Have you ever passed out or fainted during or
after exercise?
Has any family member under the age of 50 died
suddenly of a heart problem?
Have you ever been knocked unconscious, had a
skull fracture, or concussion?
Do you have seizures or epilepsy?
Have you had any sprains, broken bones,
dislocations, or torn ligament?
Have you undergone any surgery?
Have you ever had a neck injury, severe pain, or
 numbness in the neck?
Have you ever had any kidney disease or injury,
blood in the urine, or painful urination?
Have you been hospitalized?
Do you have any current skin problems?
Are you currently taking any medications?
Do you drink alcohol, smoke tobacco, or used
prohibited drugs?
Have you been told you could not participate in
sports/ Physical Education activities in the past?

Please describe the details for any of the yes answers:

Parent/Guardian’s statement:
I have reviewed and answered the questions above to the best of
my knowledge. I understand and accept that there are risks of serious
injury in any sport, including the one(s) in which he/she has chosen to
participate. I hereby give permission for my son/daughter to participate
in sports and P.E. activities.
I hereby authorize the emergency medical treatment personnel
and/or transportation to the medical facility for any injury or illness to
deem urgently whatever is necessary first aid by a P.E. instructor, coach,
or medical practitioner.
I understand that this sports pre-participation physical examination
is not designed nor intended to substitute for any recommended regular
comprehensive health assessment and does not eliminate the risk of all
potentially lethal cardiovascular diseases.

Parent’s signature:

Student’s signature:
Date:

B. Physical Examination:
Height: 163 cm. Weight: 64 kg. BMI: 24.2
Vital signs: BP: RR: PR: Temp.: LMP:
HEENT:
Heart:
Chest and Lungs:
Abdomen:
Extremities (Muscle-Skeletal):
Neurologic:

Recommendation:
Elisa C. Arabiana, M.D 21/03/2023
Lic. No. 60699 Date