Republic of the Philippines MCForm - 1

Revised as of September 26, 2019 DEPARTMENT OF EDUCATION

ZAMBOANGA PENINSULA
(REGION)
ZAMBOANGA DEL SUR
(DIVISION)
SAN MIGUEL ELEMENTARY SCHOOL
(SCHOOL)
KAGAWASAN, DIMATALING ZDS
(School Address)

MEDICAL CERTIFICATE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
ZAMBOANGA PENINSULA
(REGION)
ZAMBOANGA DEL SUR
(DIVISION)
School/Intrams/District Meet Remarks/Findings:
To Whom It May Concern: SAN MIGUEL ELEMENTARY SCHOOL
(SCHOOL) _____________________________ Ht ._______cm FIT
KAGAWASAN, DIMATALING ZDS Physician/Medical Officer Wt:_______kg
This is to certify that I have personally examined __________________age 12(School
sex Address) (signature over printed name) BP.____________mmHg UNFIT
Name
PRC PR:____________bpm
_____ and have found that he/she is physically fit unfit, during the time of LICENSE: PTR NO. RR:____________cpm Date:
examination, to join and participate in the lower meets up to Palarong Pambansa. Unit/Division Meet Remarks/Findings:

Event: __________________ _____________________________ Ht ._______cm FIT

Physician/Medical Officer Wt:_______kg
Physical Examination (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
School/ Unit/Division Regional Palarong LICENSE: PTR NO. RR:____________cpm Date:
Intrams/District Meet Meet Pambansa Regional Meet Remarks/Findings:
Meet
Normal Normal Normal Normal _____________________________ Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
1. Eyes YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO
Palarong Pambansa Remarks/Findings:
4. Neck YES | NO YES | NO YES | NO YES | NO
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg
7. Abdomen YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
8. Skin YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date:
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)