This medical certificate documents a physical examination of a student athlete. It records the examination of various body parts and systems and whether they are normal or abnormal for participation in school sports competitions at different levels, from intramural to regional to national meets. The form is signed by a physician.
This medical certificate documents a physical examination of a student athlete. It records the examination of various body parts and systems and whether they are normal or abnormal for participation in school sports competitions at different levels, from intramural to regional to national meets. The form is signed by a physician.
This medical certificate documents a physical examination of a student athlete. It records the examination of various body parts and systems and whether they are normal or abnormal for participation in school sports competitions at different levels, from intramural to regional to national meets. The form is signed by a physician.
This medical certificate documents a physical examination of a student athlete. It records the examination of various body parts and systems and whether they are normal or abnormal for participation in school sports competitions at different levels, from intramural to regional to national meets. The form is signed by a physician.
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Republic of the Philippines MCForm - 1
Revised as of September 26,
2019 DEPARTMENT OF EDUCATION
VII (REGION)
NORTHERN SAMAR (DIVISION)
ST. ANTHONY ACADEMY
(SCHOOL)
BRGY. CHITONGCO, MONDRAGON, NORTHERN SAMAR
(School Address)
MEDICAL CERTIFICATE e. hips YES | NO YES | NO YES | NO YES | NO To Whom It May Concern: f. thighs YES | NO YES | NO YES | NO YES | NO g. knees YES | NO YES | NO YES | NO YES | NO This is to certify that I have personally examined ___________________ age h. ankles YES | NO YES | NO YES | NO YES | NO Name ____ sex _____ and have found that he/she is physically fit unfit, during i. feet YES | NO YES | NO YES | NO YES | NO 11. Neuromuscular YES | NO YES | NO YES | NO YES | NO the time of examination, to join and participate in the lower meets up to Palarong (reflexes) Pambansa. Event: ___________________________ School/Intrams/District 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 Unit/Division Meet 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 4. Neck YES | NO YES | NO YES | NO YES | NO PRC PR:____________bpm LICENSE: PTR NO. RR:____________cpm 5. Cardiovascular YES | NO YES | NO YES | NO YES | NO Date: Regional Meet Remarks/Findings: 6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO 7. Abdomen YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT 8. Skin YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer Wt:_______kg 9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg UNFIT PRC PR:____________bpm 10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO LICENSE: PTR NO. RR:____________cpm Date: a. neck YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings: b. spine YES | NO YES | NO YES | NO YES | NO c. shoulder YES | NO YES | NO YES | NO YES | NO _____________________________ Ht ._______cm FIT Physician/Medical Officer Wt:_______kg d. arms/hands YES | NO YES | NO YES | NO YES | NO (signature over printed name) BP.____________mmHg
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
