Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
III – CENTRAL LUZON
(Region)
________________________
(Division)
______________________________
(School)
______________________________
(School Address)

Athlete’s Name:_______________________________________
Birthdate:___________________ Date of Examination: ___________________
MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES | NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or YES | NO
told you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, YES | NO
allergy)?
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES | NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES | NO
5. Have you ever spent the night in a hospital? YES | NO
6. Have you ever had surgery? YES | NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES | NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES | NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES | NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES | NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress YES | NO
test)
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES | NO
13. Have you ever had an unexplained seizure? YES | NO
14. Do you get more tired or short of breath more quickly than your friends during YES | NO
exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or YES | NO
unexplained sudden deaths before the age of 50 (including unexplained drowning,
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near YES | NO
drowning?
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES | NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES | NO
19. have you ever had an injury that requires x-ray for neck instability? YES | NO
20. Do you regularly use a brace or other assistive device? YES | NO
21. Do you have a bone, muscle or joint injury that bothers you? YES | NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES | NO
MEDICAL QUESTIONS
23. Has a doctor ever told you that you have asthma or allergies? YES | NO
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES | NO
or after exercise?
25. Is there anyone in your family who has asthma? YES | NO

YES | NO REMARKS

1 of 2 MCForm – 2
 Republic of the Philippines MCForm - 2
Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
III – CENTRAL LUZON
(Region)
________________________
(Division)
______________________________
(School)
______________________________
(School Address)

This form must be completed and signed by the parent/guardian, prior to the physical
examination, for review by examining practitioner. Explain ‘YES’ answers in the
REMARKS.
26. Have you ever used an inhaler or taken asthma medicine? YES | NO
27. Do you develop a rash or hives when you exercise? YES | NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES | NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES | NO
30. Have you ever had Dengue hemorrhagic fever infection? YES | NO
31. Do you have any rashes, pressure sores or other skin problems? YES | NO
32. Have you ever had a head injury or concussion? YES | NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES | NO
headache or memory problem?
34. Have you ever had a history of seizure (convulsion)? YES | NO
35. Do you have headaches with exercise? YES | NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES | NO
or falling?
37. Have you ever been unable to move your arms or legs after being hit or falling? YES | NO
38. Have you ever become ill after exercising in the heat? YES | NO
39. Do you get frequent muscles cramps when exercising? YES | NO
40. Have you had any problems with your eyes or vision? YES | NO
41. Have you had any eye injuries? YES | NO
42. Do you wear glasses or contact lens? YES | NO
43. Do you wear protective eyewear such as goggles or face shield? YES | NO
44. Do you have any concerns that you would like to discuss with a doctor? YES | NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES | NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES | NO
FEMALES ONLY
47. Have you ever had a menstrual period? YES | NO
48. Have you ever had mestrual cramps? YES | NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?

NOTES:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
___

I do not know of any existing physical or addition health reason that would preclude participation in
sports. I certify that the answers to the above questions are true and accurate and I approve
participation in the athletic activities.

______________________________________ ________________________________
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

_____________________
Date

2 of 2 MCForm – 2