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FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
02
(Region)
Province of Isabela
(Division)
RANIAG HIGH SCHOOL
(School)
Raniag, Ramon, Isabela
(School Address)
Name
M E D I C A L C E R T I F I C A T E
To Whom It May Concern:
This is to certify that I have personally examined _______________________
age ___ sex ____ 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: _________________________________
Physical Examination
School/Intrams/
District Meet
Unit/Division
Meet
Regional
Meet
Palarong
Pambansa
Normal Normal Normal Normal
1. Eyes YES | NO YES | NO YES | NO YES | NO
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO
4. Neck YES | NO YES | NO YES | NO YES | NO
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO
7. Abdomen YES | NO YES | NO YES | NO YES | NO
8. Skin YES | NO YES | NO YES | NO YES | NO
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
(reflexes)
YES | NO YES | NO YES | NO YES | NO
School/Intrams/District Meet
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE: PTR NO.
Remarks/Findings:
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
FIT
UNFIT
Date:
Unit/Division Meet
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE: PTR NO.
Remarks/Findings:
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
FIT
UNFIT
Date:
Regional Meet
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE: PTR NO.
Remarks/Findings:
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
FIT
UNFIT
Date:
Palarong Pambansa
_____________________________
Physician/Medical Officer
(signature over printed name)
PRC
LICENSE: PTR NO.
Remarks/Findings:
Ht ._______cm
Wt:_______kg
BP.____________mmHg
PR:____________bpm
RR:____________cpm
FIT
UNFIT
Date:
Revised as of September 26, 2019

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  • 1. FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa) Republic of the Philippines MCForm - 1 DEPARTMENT OF EDUCATION 02 (Region) Province of Isabela (Division) RANIAG HIGH SCHOOL (School) Raniag, Ramon, Isabela (School Address) Name M E D I C A L C E R T I F I C A T E To Whom It May Concern: This is to certify that I have personally examined _______________________ age ___ sex ____ 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: _________________________________ Physical Examination School/Intrams/ District Meet Unit/Division Meet Regional Meet Palarong Pambansa Normal Normal Normal Normal 1. Eyes YES | NO YES | NO YES | NO YES | NO 2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO 3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO 4. Neck YES | NO YES | NO YES | NO YES | NO 5. Cardiovascular YES | NO YES | NO YES | NO YES | NO 6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO 7. Abdomen YES | NO YES | NO YES | NO YES | NO 8. Skin YES | NO YES | NO YES | NO YES | NO 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 (reflexes) YES | NO YES | NO YES | NO YES | NO School/Intrams/District Meet _____________________________ Physician/Medical Officer (signature over printed name) PRC LICENSE: PTR NO. Remarks/Findings: Ht ._______cm Wt:_______kg BP.____________mmHg PR:____________bpm RR:____________cpm FIT UNFIT Date: Unit/Division Meet _____________________________ Physician/Medical Officer (signature over printed name) PRC LICENSE: PTR NO. Remarks/Findings: Ht ._______cm Wt:_______kg BP.____________mmHg PR:____________bpm RR:____________cpm FIT UNFIT Date: Regional Meet _____________________________ Physician/Medical Officer (signature over printed name) PRC LICENSE: PTR NO. Remarks/Findings: Ht ._______cm Wt:_______kg BP.____________mmHg PR:____________bpm RR:____________cpm FIT UNFIT Date: Palarong Pambansa _____________________________ Physician/Medical Officer (signature over printed name) PRC LICENSE: PTR NO. Remarks/Findings: Ht ._______cm Wt:_______kg BP.____________mmHg PR:____________bpm RR:____________cpm FIT UNFIT Date: Revised as of September 26, 2019