Republic of the Philippines MCForm - 1

Revised as of September 26,

2019 DEPARTMENT OF EDUCATION

REGION IX
(REGION)

ZAMBOANGA SIBUGAY
(DIVISION)

BALUNGISAN NATIONAL HIGH SCHOOL

(SCHOOL)

______________________________

MEDICAL CERTIFICATE
b. spine YES | NO YES | NO YES | NO YES | NO
To Whom It May Concern: c. shoulder YES | NO YES | NO YES | NO YES | NO
d. arms/hands YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined JENNIFER P. DOLLER e. hips YES | NO YES | NO YES | NO YES | NO
Name
age 16 sex F and have found that he/she is physically fit unfit, during f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
the time of examination, to join and participate in the lower level up to National
h. ankles YES | NO YES | NO YES | NO YES | NO
Schools Press Conference. i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
(reflexes)
Category: Pagsulat ng Balitang Isports

Physical Examination Division Schools Press Con Remarks/Findings:

School/ Unit/Division Regional Palarong _____________________________ Ht ._______cm FIT

Intrams/District Meet Meet Pambansa Physician/Medical Officer Wt:_______kg
Meet (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
Normal Normal Normal Normal LICENSE: PTR NO. RR:____________cpm Date:
1. Eyes YES | NO YES | NO YES | NO YES | NO Regional Schools Press Con Remarks/Findings:
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO _____________________________
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Ht ._______cm FIT
(signature over printed name) Wt:_______kg
4. Neck YES | NO YES | NO YES | NO YES | NO PRC BP.____________mmHg UNFIT
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. PR:____________bpm
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO RR:____________cpm Date:
7. Abdomen YES | NO YES | NO YES | NO YES | NO
8. Skin YES | NO YES | NO YES | NO YES | NO
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO
a. neck YES | NO YES | NO YES | NO YES | NO

FOR SCHOOL JOURNALISM (Lower level up to National level)

 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION

REGION IX
(REGION)

ZAMBOANGA SIBUGAY
(DIVISION)

BALUNGISAN NATIONAL HIGH SCHOOL

(SCHOOL)

______________________________

Regional Schools Press Conference Remarks/Findings:

_____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
National Schools Press Conference Remarks/Findings:

_____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:

FOR SCHOOL JOURNALISM (Lower level up to National level)