MCForm - 1

Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
REGION IV A CALABARZON
(Region)

SCHOOLS DIVISION OF LAGUNA

(Division)

LUMOT NATIONAL HIGH SCHOOL_

(School)

Brgy. Mahipon Cavinti, Laguna

(School Address)

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 MCForm - 1
DEPARTMENT OF EDUCATION
REGION IV A CALABARZON
(Region)

SCHOOLS DIVISION OF LAGUNA

(Division)

LUMOT NATIONAL HIGH SCHOOL_

(School)

Brgy. Mahipon Cavinti, Laguna

_____________________________ Ht ._______cm FIT
To Whom It May Concern:
(School Address)

Physician/Medical Officer Wt:_______kg

(signature over printed name) BP.____________mmHg UNFIT
This is to certify that I have personally examined RHONALYN B. JOSE PRC PR:____________bpm
Name
LICENSE: PTR NO. RR:____________cpm Date:
age ___ sex FEMALE and have found that he/she is physicall fit unfit, Unit/Division Meet Remarks/Findings:
during the time of examination, to join and participate in the lower meets up to
_____________________________ 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: BASKETBALL_ 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 _____________________________ 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
PRC PR:____________bpm
4. Neck YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO
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)

School/Intrams/District Meet Remarks/Findings:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)