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Medical For Athletes 1

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Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION


02
(REGION)
ISABELA
(DIVISION)
BALAGAN INTEGRATED SCHOOL
(SCHOOL)
BALAGAN, SAN MARIANO, ISABELA
(School Address)

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
02
(REGION)
ISABELA
(DIVISION)
BALAGAN INTEGRATED _____________________________
SCHOOL Ht ._______cm
To Whom It May Concern: Physician/Medical Officer Wt:_______kg
FIT
(SCHOOL)
BALAGAN, SAN MARIANO, (signature
ISABELA over printed name) BP.____________mmHg UNFIT
This is to certify that I have personally examined JANEA CLAINE T. TAMANG (School Address)PRC PR:____________bpm
Name
LICENSE: PTR NO. RR:____________cpm
age 13 sex FEMALE and have found that he/she is physically fit unfit, Date:

/
during the time of examination, to join and participate in the lower meets up to
Unit/Division Meet

_____________________________
Remarks/Findings:

Ht ._______cm FIT
Palarong Pambansa. Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Event: ATHLETICS Regional 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 Palarong Pambansa Remarks/Findings:
1. Eyes YES | NO YES | NO YES | NO YES | NO
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
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
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO
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
b. spine YES | NO YES | NO YES | NO YES | NO
c. shoulder YES | NO YES | NO YES | NO YES | NO
d. arms/hands YES | NO YES | NO YES | NO YES | NO
e. hips YES | NO YES | NO YES | NO YES | NO
f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
h. ankles YES | NO YES | NO YES | NO YES | NO
i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular YES | NO YES | NO YES | NO YES | NO
(reflexes)

Legislative District Meet Remarks/Findings:


FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

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