Republic of the Philippines MCForm - 1

Revised as of September 26,

2019 DEPARTMENT OF EDUCATION

VII
(REGION)

NORTHERN SAMAR
(DIVISION)

ST. ANTHONY ACADEMY

(SCHOOL)

BRGY. CHITONGCO, MONDRAGON, NORTHERN SAMAR

(School Address)

MEDICAL CERTIFICATE
e. hips YES | NO YES | NO YES | NO YES | NO
To Whom It May Concern: f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined ___________________ age h. ankles YES | NO YES | NO YES | NO YES | NO
Name
____ sex _____ and have found that he/she is physically fit unfit, during i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
the time of examination, to join and participate in the lower meets up to Palarong (reflexes)
Pambansa.
Event: ___________________________ School/Intrams/District Meet Remarks/Findings:

Physical Examination _____________________________ Ht ._______cm FIT

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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION

VII
(REGION)

NORTHERN SAMAR
(DIVISION)

PRC PR:____________bpm UNFIT ST. ANTHONY ACADEMY

LICENSE: PTR NO. RR:____________cpm (SCHOOL)

BRGY.
Date:CHITONGCO, MONDRAGON, NORTHERN SAMAR
(School Address)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)