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KURT-Medical For Athletes 2
KURT-Medical For Athletes 2
DEPARTMENT OF EDUCATION
NCR
(Region)
MANILA CITY
(Division)
MANILA CATHEDRAL SCHOOL
(School)
287 Tayuman St. Tondo Manila
(School Address)
MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for
review by the examining practitioner. Explain ‘YES’ answers below with the number of the question.
GENERAL QUESTIONS YES | REMARKS
NO
1. Has a doctor ever denied or restricted your participation in sports for any YES | NO
reason or told you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, YES | NO
infarctions, allergy)?
3. Are you currently taking any prescription or nonprescription (over-the- YES | NO
counter) medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES | NO
NOTES:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
___
I do not know of any existing physical or additional health reason that would preclude participation in
sports. I certify that the answers to the above questions are true and accurate and I approve
participation in the athletic activities.
2 of 2 MCForm – 2
Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
NCR
(Region)
MANILA CITY
(Division)
MANILA CATHEDRAL SCHOOL
(School)
287 Tayuman St. Tondo Manila
(School Address)
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name
Date : JANUARY 31, 2024
3 of 2 MCForm – 2