Republic of the Philippines

DEPARTMENT OF EDUCATION
_________REGION III___________
(Region)

OLONGAPO CITY
(Division)

______________________________
(School)

______________________________
(School Address)
MEDICAL CERTIFICATE

REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW)

(FOR ANY

DATE OF EXAMINATION: _________________________________

If Athlete had a Concussion in

Medical Examination following post

the past year.

period after Concussion was normal.

ABNORMALITIES)

Normal

Abnormal

(record)
Mouth, teeth, throat, nose
Temporomandibular joint
Cervical spine, lymph nodes
Breath sounds, rib

Normal
Normal
Normal
Normal

Abnormal
Abnormal
Abnomal
Abnomal

tenderness on compession
Pulse/ blood pressure

Normal

Abnormal

Normal

Abnormal

Normal

Abnormal

Normal
Normal
Normal
Normal
Normal
Yes

Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
No

Please note if any:

____________________________
List of abnormalities not covered in
General Medical Exam

specific system exams below:

Mental Status/ Psychological

Brief survey
Cranial nerves, eyes, pupil size and

(a) Head

(b) Neck
(c) Chest

(d) Cardio Vascular

System

reactivity.

(record)
Heart

Fundi,

Vision

by

examination:

chart

sounds,

murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

(e) Orthopedic System

(f) Neurological System

(g) Asthma
(h) Allergies
(i) Medications used

fingers
Lower limb: (ankle, knee, hip)
Relaxes
Verbal responses
Motor responses and balance
(record)
Type of reaction (record)
Name and dosage (record)

Name of Athlete: ____________________________________

Yes

Fit to Play

No

Not Fit to Play

Name of MD:
________________________________________

License Number:______________________________

FOR PALARONG PAMBANSA ONLY