Republic of the Philippines MCForm - 1

Revised as of September 26, 2019

DEPARTMENT OF EDUCATION

MIMAROPA
(REGION)

ORIENTAL MINDORO
(DIVISION)

STA. ISABEL ELEMENTARY SCHOOL

(SCHOOL)

MEDICAL CERTIFICATE
g. knees YES | NO YES | NO YES | NO YES | NO
To Whom It May Concern: h. ankles YES | NO YES | NO YES | NO YES | NO
i. feet YES | NO YES | NO YES | NO YES | NO
This is to certify that I have personally examined
11. Neuromuscular (reflexes) YES | NO YES | NO YES | NO YES | NO
___________________ age ____ sex MALE and have found that he/she is
physically fit unfit, during the time of examination, to join and School/Intrams/District Meet Remarks/Findings:
participate in the lower meets up to Palarong Pambansa. _____________________________
Physician/Medical Officer Ht ._______cm FIT
(signature over printed name) Wt:_______kg
Event: FOOTBALL (9-12) PRC BP.____________mmHg UNFIT
LICENSE: PTR NO. PR:____________bpm
Physical Examination RR:____________cpm Date:
School/ Unit/Division Regional Meet Palarong Unit/Division Meet Remarks/Findings:
Intrams/District Meet Pambansa ____________________________P
Meet hysician/Medical Officer Ht ._______cm FIT
Normal Normal Normal Normal (signature over printed name) Wt:_______kg
PRC BP.____________mmHg
1. Eyes YES | NO YES | NO YES | NO YES | NO UNFIT
LICENSE: PTR NO. PR:____________bpm
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO RR:____________cpm Date:
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO
Regional Meet Remarks/Findings:
4. Neck YES | NO YES | NO YES | NO YES | NO _____________________________
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Ht ._______cm FIT
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO (signature over printed name) Wt:_______kg
7. Abdomen YES | NO YES | NO YES | NO YES | NO PRC BP.____________mmHg UNFIT
8. Skin YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. PR:____________bpm
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 Palarong Pambansa Remarks/Findings:
_____________________________
a. neck YES | NO YES | NO YES | NO YES | NO
Physician/Medical Officer Ht ._______cm FIT
b. spine YES | NO YES | NO YES | NO YES | NO (signature over printed name) Wt:_______kg
c. shoulder YES | NO YES | NO YES | NO YES | NO PRC BP.____________mmHg UNFIT
d. arms/hands YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. PR:____________bpm
e. hips YES | NO YES | NO YES | NO YES | NO RR:____________cpm Date:
f. thighs YES | NO YES | NO YES | NO YES | NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION

MIMAROPA
(REGION)

ORIENTAL MINDORO
(DIVISION)

STA. ISABEL ELEMENTARY SCHOOL

(SCHOOL)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)