Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

VIII
(REGION)
SAMAR
(DIVISION)
CAPAYSAGAN ELEMENTARY SCHOOL
(SCHOOL)
Capaysagan, Motiong, Samar
(School Address)

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
VIII
(REGION)
SAMAR
(DIVISION)
School/Intrams/District Meet Remarks/Findings:
To Whom It May Concern: CAPAYSAGAN ELEMENTARY SCHOOL
(SCHOOL) _____________________________ Ht ._______cm FIT
Capaysagan, Motiong, Samar Physician/Medical Officer Wt:_______kg
This is to certify that I have personally examined ___________________ (School Address) (signature over printed name) BP.____________mmHg UNFIT
Name
PRC PR:____________bpm
age ____ sex _____ and have found that he/she is physically fit unfit, LICENSE: PTR NO. RR:____________cpm Date:
during the time of examination, to join and participate in the lower meets up to Unit/Division Meet Remarks/Findings:

Palarong Pambansa. _____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
Event: ___________________________ LICENSE: PTR NO. RR:____________cpm Date:
Regional Meet Remarks/Findings:
Physical Examination
_____________________________ Ht ._______cm FIT
School/ Unit/Division Regional Palarong Physician/Medical Officer Wt:_______kg
Intrams/District Meet Meet Pambansa (signature over printed name) BP.____________mmHg UNFIT
Meet PRC PR:____________bpm
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
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
(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)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)