Date: ____ April 2023

MEDICAL CERTIFICATE

I hereby certify that I have seen and examined ____________________________,

(Name)
____ years old, □ male □ female, _________, from _________________________________,
(Age) (Civil Status) (Address)
___________ in ________________________________________, with the following findings:
(Grade Level) (School)

Height: _____ meters Blood Pressure: ______ mmHg Heart Rate: ___ bpm
Weight: _____ kg Respiratory Rate: ____/ min Temperature: ____ °C

COVID-19 vaccination status: □ Unvaccinated □ Partially vaccinated

□ Fully vaccinated □ Fully vaccinated with booster,
No. of booster doses: _______

Clinical Impression:______________________________________________________

__________________________________________________________________________________

Remarks: _________________________________________________________________

__________________________________________________________________________________

Issued this ____ day of April 2024 for reference use only and not for medico-
legal purposes.

________________________________________
Physician’s Signature over Printed Name
 1st. SOCORRO V. DELA ROSA SPORTS CUP
Date: ____ February 2023

DENTAL FINDINGS

Name: ___________________________________________________ Age/ Sex: __________

Decayed (D): _____ Oral Health Conditions: □ Gingivitis

Missing (M): _____ □ Periodontal disease
Filled (F): _____ □ Malocclusion
Total DMFT: _____ □ Supernumerary teeth
For extraction: _____ □ Retained deciduous teeth
For filling: _____ □ Decubital ulcer
□ Calculus
□ Cleft lip/ palate
□ Root fragment
□ Fluorosis
Others: __________________

Remarks: ________________________________________________________________________

________________________________________
Dentist II