Republic of the Philippines
Revised as of September 26, 2019
MCForm - 1
DEPARTMENT OF EDUCATION
Region VII
DUMAGUETE CITY DIVISION
CAMANJAC NATIONAL HIGH SCHOOL
CAMANJAC, DUMAGUETE CITY
MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MA. ZENITH A. CASTRO
Name
age _16_ sex F and have found that he/she is physically
fit
unfit,
during the time of examination, to join and participate in the lower meets up to
Palarong Pambansa.
Event: TAEKWONDO
Physical Examination
1. Eyes
2. Ears, Nose, Throat
3. Mouth and Teeth
4. Neck
5. Cardiovascular
6. Chest and Lungs
7. Abdomen
8. Skin
9. Genitalia-Hernia (male)
10. Muskuloskeletal: ROM
a. neck
b. spine
c. shoulder
d. arms/hands
e. hips
School/Intrams/
District Meet
Unit/Division
Meet
Regional
Meet
Palarong
Pambansa
Normal
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
Normal
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
Normal
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
Normal
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
YES | NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
f. thighs
g. knees
h. ankles
i. feet
11. Neuromuscular
(reflexes)
YES
YES
YES
YES
YES
|
|
|
|
|
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
|
|
|
|
|
School/Intrams/District Meet
Remarks/Findings:
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
Unit/Division Meet
Remarks/Findings:
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
Regional Meet
Remarks/Findings:
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
Palarong Pambansa
Remarks/Findings:
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
|
|
|
|
|
NO
NO
NO
NO
NO
FIT
UNFIT
Date:
FIT
UNFIT
Date:
FIT
UNFIT
Date:
FIT
UNFIT
Date:
YES
YES
YES
YES
YES
|
|
|
|
|
NO
NO
NO
NO
NO