Republic of the Philippines MCForm - 1

Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
CARAGA
(REGION)
BUTUAN CITY
(DIVISION)

LIBERTAD CENTRAL ELEMENTARY SCHOOL

(SCHOOL)
LIBERTAD, BUTUAN CITY
(School Address)

MEDICAL CERTICATE
f. thighs YES | NO YES | NO YES | NO YES | NO
To Whom It May Concern: g. knees YES | NO YES | NO YES | NO YES | NO
h. ankles YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined JIANT DELGADO ABESAMIS i. feet YES | NO YES | NO YES | NO YES | NO
Name
Age 10 sex _FEMALE and have found that he/she is physically fit unfit, during 11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
(reflexes)
the time of examination, to join and participate in the lower meets up to Palarong School/Intrams/District Meet Remarks/Findings:
Pambansa. _________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
Event: _TAEKWONDO POOMSAE (GIRLS)
(signature over printed name) BP.____________mm
PRC Hg UNFIT
Physical Examination LICENSE: PTR NO. PR:____________bpm
RR:____________cpm Date:
School/ Unit/Division Regional Palarong
Intrams/District Meet Meet Pambansa Unit/Division Meet Remarks/Findings:
Meet
__________________________ Ht ._______cm FIT
Normal Normal Normal Normal ___Physician/Medical Officer Wt:_______kg
1. Eyes YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mm
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO PRC Hg UNFIT
LICENSE: PTR NO. PR:____________bpm
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO RR:____________cpm Date:
4. Neck YES | NO YES | NO YES | NO YES | NO Regional Meet Remarks/Findings:
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO
__________________________ Ht ._______cm FIT
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO ___Physician/Medical Officer Wt:_______kg
7. Abdomen YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mm
8. Skin YES | NO YES | NO YES | NO YES | NO PRC Hg UNFIT
LICENSE: PTR NO. PR:____________bpm
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO RR:____________cpm Date:
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings:
a. neck YES | NO YES | NO YES | NO YES | NO
b. spine YES | NO YES | NO YES | NO YES | NO __________________________ Ht ._______cm FIT
___ Physician/Medical Officer Wt:_______kg
c. shoulder YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mm
d. arms/hands YES | NO YES | NO YES | NO YES | NO PRC Hg UNFIT
e. hips YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. PR:____________bpm

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
CARAGA
(REGION)
BUTUAN CITY
RR:____________cpm Date: (DIVISION)

LIBERTAD CENTRAL ELEMENTARY SCHOOL

(SCHOOL)
LIBERTAD, BUTUAN CITY
(School Address)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)