Republic of the Philippines
Revised as of April 3 ,2023
MCForm - 1
DEPARTMENT OF EDUCATION
________________________
(REGION)
______________________________
(DIVISION)
______________________________
(SCHOOL)
MEDICAL CERTIFICATE
______________________________
(School Address)
To Whom It May Concern:
g. knees
h. ankles
i. feet
11. Neuromuscular
(reflexes)
This is to certify that I have personally examined ___________________
Name
age ____ sex _____ and have found that he/she is physically
fit
f. thighs
unfit,
YES | NO
YES | NO
YES | NO
YES | NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
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NO
NO
NO
NO
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NO
NO
NO
NO
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NO
NO
NO
NO
during the time of examination, to join and participate in the lower meets up to
Palarong Pambansa.
Event: ___________________________
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
Normal
Normal
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
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NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
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NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Regional
Meet
Palarong
Pambansa
Normal
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
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NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Normal
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
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NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
School/Intrams/District Meet
Remarks/Findings:
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Unit/Division Meet
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
_____________________________Phy
sician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Regional Meet
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
_____________________________Phy
sician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Palarong Pambansa
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE:
PTR NO.
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
FIT
UNFIT
Date:
Remarks/Findings:
FIT
UNFIT
Date:
Remarks/Findings:
FIT
UNFIT
Date:
Remarks/Findings:
FIT
UNFIT
Date:
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NO
NO
NO
NO
Republic of the Philippines
DEPARTMENT OF EDUCATION
________________________
(REGION)
______________________________
(DIVISION)
______________________________
(SCHOOL)
______________________________
(School Address)
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
MCForm - 1