Republic of the Philippines

DEPARTMENT OF EDUCATION
________________________
(REGION)
______________________________
(DIVISION)
______________________________
(SCHOOL)
______________________________
(School Address)

MEDICAL CERTIFICATE REMARKS QUESTION FOR ATHLETE YES NO REMARKS BY PARENT

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY TO BE ANSWERED BY THE
DATE OF EXAMINATION: _________________________________ ABNORMALITIES) PARENT:
Is a doctor currently treating you for
If Athlete had a Concussion in the Medical Examination anything?
past year. following post period after Normal Abnormal
Please note if any: Concussion was normal. Have you ever been unconscious or
____________________________ had a concussion?

List of abnormalities not Have you been hit hard in

General Medical Exam covered in specific system the head in the last 6 weeks?
Mental Status/ Psychological exams below:
Brief survey Have you had any headache in the
Cranial nerves, eyes, pupil last 2 week?
Head size and reactivity. Fundi,
Vision by chart (record) Normal Abnormal Do you have any problem in
Mouth, teeth, throat, nose Normal Abnormal bleeding?
Temporomandibular joint Normal Abnomal
Does any disease run in your
Cervical spine, lymph Normal Abnomal family? Sudden unexfected death?
Neck nodes
Breath sounds, rib Have you had any surgery?
Chest tenderness on compession Normal Abnormal
Pulse/ blood pressure Have you ever had to stay in a
(record) Normal Abnormal hospital?
(d) Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, Normal Abnormal
rhythm Name of Athlete: ____________________________ Fit to Play Not Fit to Play
Upper limb: shoulder Signature Overprinted Name of Parent: ___________________________
(e) Orthopedic System wrist, hand, fingers Normal Abnormal
Lower limb: (ankle, knee, Normal Abnormal District Meet Date Examined: Regional Meet Date Examined:
hip)
___________________________________ __________________________________
Relaxes Normal Abnormal Physician/Medical Officer Physician/Medical Officer
(f) Neurological System Verbal responses Normal Abnormal PRC: PRC:
Motor responses and Normal Abnormal LICENSE: PTR NO. LICENSE: PTR NO.
balance Division Meet Date Examined: Palarong Pambansa Date Examined:
(g) Asthma (record) Yes No ___________________________________ _______________________________________
(h) Allergies Type of reaction (record) Physician/Medical Officer _ Physician/Medical Officer
(i) Medications used Name and dosage (record) Yes No PRC: PRC:
LICENSE: PTR NO. LICENSE: PTR NO.

FOR PALARONG PAMBANSA ONLY