Ja Medico Legal

REPUBLIC OF THE PHILIPPINES
NATIONAL CAPITAL JUDICIAL REGION

METROPOLITAN TRIAL COURT
________________, CALOOCAN CITY
PEOPLE OF THE PHILIPPINES,

Complainant,
Criminal Case No.

_____________
- versus - For: Slight Physical
Injuries
_________________________________
,
Accused.
x------------------------------------------x
JUDICIAL AFFIDAVIT
OF
____________________________
Personal circumstances of the witness:
Name : ______________________
Address :
Age :
Occupation : Physician / General Surgeon
Offer of testimony:
The testimony of the witness, is being offered to prove the

following:
1. To prove that he personally knows the private
complainant in this case, _______________________.
2. To prove that he is the “attending physician /

surgeon on duty” who examined the private complainant on 28
June 2019 at Caloocan City Medical Center;
3. To prove that based on his “Diagnosis”, the private
complainant suffered “abrasions” in the nasal area and right
knee;
4. To prove that he advised the private complainant to

rest at his home for not more than nine (9) months to
recuperate from his injuries;
5. To prove that he issued a “Medico-Legal Certificate”

dated 28 June 2019;
6. To prove the other matters that are pertinent and

relevant to the petition.
7. To identify documents that are pertinent and relevant

to the present case.
8. To prove that she has executed a “Judicial Affidavit”

anent the instant petition and that she will identify the same.
I, DR. _________________, of legal age, married, Filipino,

presently residing at ________________________, under oath and
fully aware that I may face criminal liability for false testimony
or perjury, hereby state my answers to the questions prepared
by my counsel, ______________________________ at the Caloocan
City Medical Center, 450 A. Mabini Street, Poblacion, Caloocan,
Metro Manila, which shall serve as my direct testimony in the
above-captioned case.
JUDICIAL AFFIDAVIT PROPER
The following are the questions and my answers:

1. Q: Good morning, Mister Witness!
A: Good morning, ma’am.
2. Q: Mister Witness, kindly state your personal circumstances, like

name, age, address and occupation.
A: I am ___________________________, of legal age, a residence of
____________________________________, a physician and a
surgeon at Caloocan City Medical Center, ma’am.
3. Q: Do you know the private complainant, _______________, in this

case?
A: Yes, ma’am.
4. Q: Why do you know the private complainant?

A: I am the attending physician / surgeon on duty who
examined the private complainant when he went to the
Caloocan Medical Center, ma’am.
5. Q: When did you examine the private complainant, Mister

Witness?
A: I examined him on 28 June 2019, ma’am.
6. Q: Based on your examination, what are your findings about the

private complainant, if any?
A: I diagnosed the private complainant to be suffering from
abrasions in his nasal area and right knee after conducting
an examination, ma’am.
7. Q: What did you do, if any, after you diagnosed that the private
complainant was suffering from abrasions in his nasal area
and right knee, Mister Witness?
A: _________________________________________________________.
8. Q: Mister Witness, what happened thereafter, if any?

A: I advised the private complainant to rest at home for not more
than nine (9) days to recover from his injuries, ma’am.
9.Q: What is your proof, Mister Witness, that you examined the
private complainant on 28 June 2019 at Caloocan Medical
Center?
A: The “Medico - Legal Certificate” I issued to the private
complainant, ma’am.
10.Q: What is your proof, Mister Witness, that after examining the
private complainant, you diagnosed him to be suffering from
abrasions in his nasal area and right knees?
11.Q: What is your proof, Mister Witness, that you advised the
private complainant to rest at his home for not more than
nine (9) months to recover from his injuries?
12.Q: If the said “Medico - Legal Certificate” will be shown to you,

will you be able to identify the same?
A: Yes, ma’am.
13.Q: I am now showing to you a document denominated as

“Medico - Legal Certificate” dated 28 June 2019 with the
letterhead of “Caloocan City Medical Center”, what is the
relation of this document to the one which you mentioned
earlier?
A: It the same “Medico - Legal Certificate” that I issued to the
private complainant, ma’am.
14.Q: On the said “Medico – Legal Certificate”, particularly on the

lower right portion thereof appeared a signature above the
name “____________________________, FICS, General Surgeon”,
whose signature is that?
A: That is my signature, ma’am.
MANIFESTATION:
It is most respectfully manifested that the “Medico - Legal

Certificate” dated 28 June 2019 identified by the witness was
previously marked as Exhibit “E”, for the prosecution.
MARKING OF EXHIBIT:
It is most respectfully moved that the signature and name of the

witness identified by the witness appearing on the “Medico - Legal
Certificate” dated 28 June 2019 be bracketed and marked as
Exhibit “E-1”, for the prosecution.
15.Q: Mister Witness, do you recall executing a “Judicial Affidavit”

in relation to the instant petition?
A: Yes, ma’am.
16.Q: If the said “Judicial Affidavit” will be shown to you, will you be
able to identify the same?
A: Yes, ma’am.
17.Q: I am now showing to you a document denominated as

“JUDICIAL AFFIDAVIT OF DR. ________________________,”,
what is the relation of this document to the one that you
referred to earlier?
A: It is the same Judicial Affidavit that I executed, ma’am.
18. Q: On “Page 5” of the said Judicial Affidavit, a signature appears

on top of the typewritten name “DR.
________________________”, whose signature is that?
A: That is my signature, ma’am.
19. Q: Do you confirm and affirm the truthfulness and veracity of

everything you have stated in this “Judicial Affidavit”?
A: Yes, ma’am.
Marking of Exhibit:
It is most respectfully moved that the “Judicial Affidavit” of

the witness for the prosecution be marked as Exhibit “__”, for the
prosecution.
Further, as a duly identified by the witness, the signature

appearing above the typewritten name “DR. _______________________”
be bracketed and marked as Exhibit “__-1”, for the prosecution
20.Q: That would be all, Mister Witness.

A: Thank you very much, ma’am.
IN WITNESS WHEREOF, I have hereunto affixed my signature
this ___ day of March 2023 at Caloocan City.
_____________________________
Affiant
BEFORE ME, a Notary Public for and in Caloocan City, ___ day
of March 2023 personally appeared the Affiant who has
satisfactorily proven his identity through his Competent Evidence of
Identity (_________________________________ with No. ______________
and valid until ___________________ and as the same person who
executed the foregoing Judicial Affidavit and acknowledged before
me that the same is his free and voluntary act and deed.
WITNESS MY HAND AND SEAL, this ___ day of March 2023 in

Caloocan City.
Doc. No. _________;

Page No. _________;
Book No. ________;
Series of 2023.

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REPUBLIC OF THE PHILIPPINES

NATIONAL CAPITAL JUDICIAL REGION

PEOPLE OF THE PHILIPPINES,

Criminal Case No.

Personal circumstances of the witness:

Occupation : Physician / General Surgeon

The testimony of the witness, is being offered to prove the

2. To prove that he is the “attending physician /

4. To prove that he advised the private complainant to

5. To prove that he issued a “Medico-Legal Certificate”

6. To prove the other matters that are pertinent and

7. To identify documents that are pertinent and relevant

8. To prove that she has executed a “Judicial Affidavit”

I, DR. _________________, of legal age, married, Filipino,

JUDICIAL AFFIDAVIT PROPER

The following are the questions and my answers:

2. Q: Mister Witness, kindly state your personal circumstances, like

3. Q: Do you know the private complainant, _______________, in this

4. Q: Why do you know the private complainant?

5. Q: When did you examine the private complainant, Mister

6. Q: Based on your examination, what are your findings about the

8. Q: Mister Witness, what happened thereafter, if any?

12.Q: If the said “Medico - Legal Certificate” will be shown to you,

13.Q: I am now showing to you a document denominated as

14.Q: On the said “Medico – Legal Certificate”, particularly on the

It is most respectfully manifested that the “Medico - Legal

It is most respectfully moved that the signature and name of the

15.Q: Mister Witness, do you recall executing a “Judicial Affidavit”

17.Q: I am now showing to you a document denominated as

18. Q: On “Page 5” of the said Judicial Affidavit, a signature appears

19. Q: Do you confirm and affirm the truthfulness and veracity of

It is most respectfully moved that the “Judicial Affidavit” of

Further, as a duly identified by the witness, the signature

20.Q: That would be all, Mister Witness.

WITNESS MY HAND AND SEAL, this ___ day of March 2023 in

Doc. No. _________;

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