Republic of the Philippines

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

(School Address)

Name of Athlete: ____________________________ Fit to Play Not Fit to Play QUESTION FOR ATHLETE YES NO REMARKS BY PARENT
Signature Overprinted Name of Parent: ___________________________ TO BE ANSWERED BY THE
District Meet Date Examined: Regional Meet Date Examined:
PARENT:
Is a doctor currently treating you for
___________________________________ __________________________________ anything?
Physician/Medical Officer Physician/Medical Officer
PRC: PRC: Have you ever been unconscious or
LICENSE: PTR NO. LICENSE: PTR NO. had a concussion?
Division Meet Date Examined: Palarong Pambansa Date Examined:
Have you been hit hard in
___________________________________ ____________________________________ the head in the last 6 weeks?
Physician/Medical Officer ____ Physician/Medical Officer
PRC: PRC: Have you had any headache in the
LICENSE: PTR NO. LICENSE: PTR NO. last 2 week?

Do you have any problem in

bleeding?

Does any disease run in your

family? Sudden unexfected death?

Have you had any surgery?

Have you ever had to stay in a

hospital?

FOR PALARONG PAMBANSA ONLY