Maam Maritess Mapsaa

REPUBLIC OF THE PHILIPPINE
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
KIDAPAWAN CITY DIVISION
ATHLETES DOCU
*IMPORTANT*
1. FILL ALL ATHLETE'S DATA ATHLETE 1 GAVILANGOSO, Jr. ATHLETE 10
ATHLETE 2 AÑOVER ATHLETE 11
ATHLETE 3 QUIAO ATHLETE 12
*PRINTING* ATHLETE 4 0 ATHLETE 13
1. CLICK ATHLETE 1, ETC… ATHLETE 5 0 ATHLETE 14
2. HIT Ctrl. + P. ATHLETE 6 0 ATHLETE 15
3. Hit ENTER ATHLETE 7 0 ATHLETE 16
* COACHES & CHAPERON REQUIREMENTS ARE IN THE GALLERY. ATHLETE 8 0 ATHLETE 17
ATHLETE 9 0 ATHLETE 18
IMPORTANT: DO NOT DRAG DATA, JUST COPY AND PASTE.
RONALD S. RAMONES-KIDAPAWAN CITY

HE PHILIPPINES
OF EDUCATION
SARGEN
CITY DIVISION
DOCUMENTS
0 ATHLETES DATA
0
PLACE ALL ENTRIES
0 GALLERY HERE
0
0 ID PICTURES
0
0 Note:
0 If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
0 If parents are abroad, Special Power of Attorney (SPA) is needed.
PARENTAL CONSENT MUST BE SIGNED BY MOTHER AND

FATHER. IF DECEASED, SECURE DEATH CERTIFICATE.
BACK
YEAR Region Level Event Last Name First Name MI
1 2019 XII MAPSSAA BILLIARD GAVILANGOSO, Jr. DANILO R.

2 2019 XII MAPSSAA BILLIARD AÑOVER NIÑA FE R.
3 2019 XII MAPSSAA BILLIARD QUIAO JESALYN D.
4 2019 XII
5 2019 XII
6 2019 XII
7 2019 XII
8 2019 XII
9 2019 XII
10 2019 XII
11 2019 XII
12 2019 XII
13 2019 XII
14 2019 XII
15 2019 XII
16 2019 XII
17 2019 XII
18 2019 XII
COACH AMANG MARITES A.
CO-COACH
CHAPERON MANOJO ARNEL L.
REGION XII
DIVISION COTABATO Athletic Meet
DATE 10/1/2019 INTRAMURALS
Name of Coach UNIT MEET
DENTIST MUNICIPAL
DOCTOR MARITES A. AMANG ZONE
DSO EDMUND ROSETE SR. ARNEL L. MANOJO PROVINCIAL
RSO DR. MAGDALENA C. DUHILAG JR. SRAA
Participation to previous Palarong Pambansa

Year of Participation Event Venue Remarks
NONE
NONE
NONE
NONE
Bdate
Sex Schoolname School Type School Address SchDiv
mm/dd/yyyy
MALE 1/12/2003 BALITE HIGH SCHOOL PUBLIC BALITE, MAGPET, COTABATO COTABATO
FEMALE 11/4/2006 BALITE HIGH SCHOOL PUBLIC BALITE, MAGPET, COTABATO COTABATO
FEMALE 02/19/2005 B.A. CALAMBA NATIONAL HIGH SCHOPUBLIC PANGAO-AN, MAGPET,COTABATO COTABATO
FEMALE 7/2/1980 BALITE HIGH SCHOOL PUBLIC BALITE, MAGPET, COTABATO COTABATO
MALE 5/15/1970 TEMPORAN NATIONAL HIGH SCHOOLPUBLIC TEMPORAN,MAGPET,COTABATO COTABATO
Athletic Meet REMARKS Remarks-PARENTAL CONSENT (A1) Remarks-PARENTAL CO

INTRAMURALS GOLD
UNIT MEET GOLD
MUNICIPAL GOLD
ZONE NONE
PROVINCIAL NONE
SRAA NONE Remarks-PARENTAL CONSENT (A2) Remarks-PARENTAL CO
Remarks-PARENTAL CONSENT (A3) Remarks-PARENTAL CO

school code LRN PLACE OF BIRTH FATHER
130074080014 BALITE, MAGPET, COTABATO DANILO, Sr. S. GAVILANGOSO

121965120037 CALBUGOS, VILLABA, LEYTE REYNALDO, S. AÑOVER
130064110091 MATAS, POBLACION, MAGPET JUVIN J. QUIAO
N/A MAKILALA, COTABATO ISARIO P. ALCALAYDE
304465 N/A SILAY CITY NEGROS OCCIDENTALWILFREDO G. MANOJO
Remarks-PARENTAL CONSENT (A6) Remarks-PARENTAL CONSENT (A11)

MOTHER GUARDIAN RELATIONSHIP
SUSAN S. ROSALES NONE N/A

RUBINA A. ROQUERO NONE N/A
ELENA D. QUIAO NONE N/A
MARIA B. ALCALAYDE NONE N/A
AURORA D. LUSADA NONE N/A
ONSENT (A11) Remarks-PARENTAL CONSENT (A16)
ONSENT (A12) Remarks-PARENTAL CONSENT (A1)7
ONSENT (A13) Remarks-PARENTAL CONSENT (A18)
ONSENT (A14)
ONSENT (A15)
HOME ADDRESS ADDRESS OF PARENTS/GUARDIAN GRADE
BALITE, MAGPET,COTABATO BALITE, MAGPET, COTABATO 11

BALITE, MAGPET,COTABATO BALITE, MAGPET, COTABATO 7
PANGAO-AN, MAGPET, COTABATO 8
BALITE, MAGPET,COTABATO POBLACION, MAGPET, COTABATO N/A
APO SANDAWA HOLMES PHASE 1 APO SANDAWA HOLMES PHASE 1
ks-PARENTAL CONSENT (A16)
ks-PARENTAL CONSENT (A1)7
ks-PARENTAL CONSENT (A18)

SECTION ADVISER REGISTRAR/PRINCIPAL SCHOOL YEAR INTRAMURALS
MAGENTA ROLAND C. MAYA REY M. LANGCUBAN 2019-2020 07/28-29/2019

HYDROGENELLY JOY S. CALAMBA REY M. LANGCUBAN 2019-2020 07/28-29/2019
N/A N/A REY M. LANGCUBAN 2019-2020 07/28-29/2019
N/A N/A ARNI B. BALEÑA 2019-2020

INCLUSIVE DATES
UNIT MEET MUNICIPAL MEET ZONE MEET
09/23 - 24/2019 10/07-08/2019 NONE

10/07-08/2019 NONE
MAGPET 10/07-08/2019 NONE

PROVINCIAL MEET SRAA Contact Number
NONE NONE 9677185157


0
REGION
0
DIVISION
BILLIARD
EVENT
COACH/ASST. COACH/CHAPERON RECORD

(CERTIFICATE OF TRAINING, RELEVANT COACHING
EXPERIENCE )
CONTRACT OF SERVICE (FOR PRIVATE)

OMNIBUS AFFIDAVIT
MEDICAL CERTIFICATE Assistant Coach/Co-Coach
AMANG, MARITES A. NAME ,

BALITE HIGH SCHOOL SCHOOL 0
COACH/ASST. COACH/CHAPERON RECORD

(CERTIFICATE OF TRAINING, RELEVANT COACHING
EXPERIENCE )
CONTRACT OF SERVICE (FOR PRIVATE)

OMNIBUS AFFIDAVIT
CHAPERON MEDICAL CERTIFICATE
CERTIFICATE OF COMMITMENT
MANOJO, ARNEL L. NAME

TEMPORAN NATIONAL HIGH SCHOOL SCHOOL
AR - 1
ORIGINAL COPY OF PSA/NSO
SF 10 / FORM - 137
CERTIFICATE OF ATTENDANCE
PARENTS CONSENT
athlete
athlete MEDICAL CERTIFICATE
DENTAL CERTIFICATE
DISABILITY ASSESSMENT
INTERVIEWED
GAVILANGOSO, Jr., DANILO R. NAME OF ATHLETE QUIAO, JESALYN D.

130074080014 LRN 130064110091
01/12/2003 DATE OF BIRTH 02/19/2005
BALITE HIGH SCHOOL SCHOOL B.A. CALAMBA NATIONAL HIGH SCHOOL
AR - 1
SF 10 / FORM - 137
athlete
A2 PARENTS CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
AÑOVER, NIÑA FE R. NAME OF ATHLETE ,

121965120037 LRN 0
01/12/2003 DATE OF BIRTH 12/30/1899
BALITE HIGH SCHOOL SCHOOL 0
All athlete interviewed and OK.
SIGNED:
DATE:
0
REGION
0
DIVISION
BILLIARD
EVENT
AR - 1
SF 10 / FORM - 137
athlete athlete
PARENTS CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
SF 10 / FORM - 137
athlete PARENTS CONSENT
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
SF 10 / FORM - 137
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
SF 10 / FORM - 137
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
SIGNED:
DATE:
0
REGION
0
DIVISION
BILLIARD
EVENT
AR - 1
SF 10 / FORM - 137
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
SF 10 / FORM - 137
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE ,
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
SF 10 / FORM - 137
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
AR - 1
SF 10 / FORM - 137
athlete
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
, NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
SIGNED:
DATE:
BACK
BACK
GAVILANGOSO JR.,
A1 DANILO R. A7 A13
GRADE 11 - MAGENTA
AÑOVER, NIÑA FE R.
A2GRADE 7 - HYDROGEN A8 A14
A3 A9 A15
A4 A10 A16
A5 A11 A17
A6 A12 A18
AMANG, MARITES A. ARNEL L. MANOJO
COACHCOACH COACH/ASST.COACH CHAPERON
BACK
Revised July 2019
AR-I (ATHLETE RECORD)
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: GAVILANGOSO, Jr. DANILO

(Last) (First)
Sex: MALE Learner Reference Number (LRN) 130074080014 Contact Number 9677185157
Date of Birth:
(mm/dd/yyyy) 01/12/2003 Age: 16 Place of Birth: BALITE, MAGPET, COTABATO
School: BALITE HIGH SCHOOL Grade Level 11
Address of School: BALITE, MAGPET, COTABATO
Present Address: BALITE, MAGPET,COTABATO
Parents: DANILO, Sr. S. GAVILANGOSO SUSAN S. ROSALES
Fathers Name Mother/Guardian
Address of Parents: BALITE, MAGPET, COTABATO
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
07/28-29/2019 BILLIARD INTRAMURALS GOLD
09/23 - 24/2019 BILLIARD UNIT MEET GOLD
10/07-08/2019 BILLIARD MUNICIPAL GOLD
NONE BILLIARD ZONE NONE
BILLIARD PROVINCIAL NONE
BILLIARD
(Use separate sheet if necessary)
GAVILANGOSO, Jr., DANILO R.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.
Name and Signature of

Name and Signature of Regi
Division/Regional Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
ZONE MARITES A. AMANG EDMUND ROSETE SR. DR. MAGDALENA C. DUHILA
PROVINCIAL ARNEL L. MANOJO EDMUND ROSETE SR. DR. MAGDALENA C. DUHILA
0 0 EDMUND ROSETE SR. DR. MAGDALENA C. DUHILA

Screened by:
Division Meet Regional Meet Palarong Pambansa
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name
Date: ______________ Date: ______________ Date: ______________
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines
XII
Region
COTABATO
Division
Name: GAVILANGOSO, Jr., DANILO R. Age: 16
Home Address: BALITE, MAGPET,COTABATO Gender: MALE

School: BALITE HIGH SCHOOL
School Address: BALITE, MAGPET, COTABATO
Date Accomplished:
MEDICAL EXAMINATION FORM

HISTORY ( To be filled up by the learner together with the parents/guardian) YES NO
1 Are you feeling alright today?
2 Are you taking medications for the last seven days?
3 In the last twelve (12) months, have you had any head injury/trauma?
4 Have you undergone any surgical operations?
5 For the past twelve (12) months, have you had any of the following?
a) Loss of conciousness.
b) Blurring of vision/squinting.
c) Episode of nose bleeding.
d) Difficulty of breathing.
e) Easyfatiguability.
f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
l) Others (ex. Headache, Migrane)
6 Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. Dizziness, Vomiting)
7 Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia-indicate number of doses
e) Other vaccines
GAVILANGOSO, Jr., DANILO R. DANILO, Sr. S. GAVILANGOSO SUSAN S. ROSALE
Signature of Learner over printed name Signature of Parent/Guardian over printed name

XII
Region
COTABATO
Division
Name: GAVILANGOSO, Jr., DANILO R. Age: 16

Home Address: BALITE, MAGPET,COTABATO Gender: MALE
Date Accomplished:
PHYSICAL EXAMINATION
Vital Signs
Height: meter Weight: kg.
Blood Pressure: mmHg Pulse rate: beats/min
Respiratory Rate: cycles/min
REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

HEAD & NECK
EYES, EARS, NOSE & THROAT
CHEST & LUNGS
ABDOMEN
EXTREMITIES
Pupils equally reactive to light and accommodation: YES NO

REFLEXES: RIGHT LEFT OTHER FINDINGS
WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
RECOMMENDATION: REASON:
PHYSICALLY FIT TO PLAY
DEFERRED TEMPORARILY
DEFERRED PERMANENTLY
0
NAME AND SIGNATURE OF PHYSICIAN
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
BALITE HIGH SCHOOL
School
BALITE, MAGPET, COTABATO
School Address
CERTIFICATE OF ENROLMENT AND ATTENDANCE
Date: 10/01/2019
To Whom It May Concern:

This is to certify that GAVILANGOSO, Jr., DANILO R.
been enrolled at the beginning of the current school year and has attended classes up to this date.
ROLAND C. MAYA REY M. LANGCUBAN

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

HOME Republic of the Philippines
ECORD) DEPARTMENT OF EDUCATION
XII
Region
COTABATO
Division
BALITE HIGH SCHOOL
School
School Address
PARENT'S CONSENT
R. I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) GAVILANGOSO, Jr., DANILO R. in BILLIARD
9677185157 up to the Palarong Pambansa.
AGPET, COTABATO
I/We have considered the benefits that my son or daughter will derive from his/he
this activity provided that due care, diligence and necessary precautions will be observed to ens
and safety.
OSALES
ardian Further, I/We authorize the personnel of Department of Education to collect, proc
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act
able below
Remarks
0 DANILO, Sr. S. GAVILANGOSO SUSAN S. ROSALE
0 Signature of Father Over Printed Name Signature of Mother Over P
0
0
NONE
Remarks Signature of Guardian over Printed Name
GOLD
GOLD N/A
GOLD (Relationship with the Athlete)
NONE
NONE ROLAND C. MAYA REY M. LA
Adviser School Hea
(Signature Over Printed Name) (Signature Ove
he lower meets.
Remarks:
e and Signature of Regional
AGDALENA C. DUHILAG JR.

0
0
Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher.
If parents are abroad, Special Power of Attorney (SPA) is needed.
SAC over Printed Name)
___

XII
Region
COTABATO
Division
DENTAL HEALTH RECORD
Name: GAVILANGOSO, Jr., DANILO R. 10/01/2019

Age: 16 Sex: MALE Birth Date: 01/12/2003 DATE
Event: BILLIARD
Parent/Guardian: DANILO, Sr. S. GAVILANGOSO SUSAN S. ROSALES
Coach: MARITES A. AMANG
REMARKS CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
SYMBOLS FOR MOUTH EXAMINATION SYMBOL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT
FOR EXTRACTION MAL -
MALOCLUSSION xt
F - TOOTH INDICATED FLU -
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
HEAVY - TOOTH WITH TEMPORARY Gm -
MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) AR
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC
RF - ROOT FRAGMENT (3-4 QUADRANTS) I
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP
USAN S. ROSALES (√) - SOUND ERUPTED PERMANENT ZOE
over printed name TOOTH TF
R
UN
District Meet Remarks/Findings:

0 WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR:
DENTIST YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
BALITE HIGH SCHOOL
School
School Address
MEDICAL CERTIFICATE
(BASED ON VISUAL, PHYSICAL ASSESSMENT AND INTERVIEW) DATE REMARKS
OF EXAMINATION: ___________________________________________________ (FOR A
If athlete has a concussion in Medical examination

the past years. following post period after
Please note if any concussion was normal. Normal Abnormal
___________________
List of abnormalities not

General Medical Exam. covered in specific system
Mental status/Psychological exams below; Brief survey
REMARKS
Carnial nerves, eyes, pupil,
size and reactivity. Fundi,
vision by chart(record) Normal Abnormal
Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, Lymph nodes Normal Abnormal
Breath sound, Rib
Chest tenderness on compression Normal Abnormal
Pulse/Blood pressure(record) Normal Abnormal

NDINGS Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, rhythm
Normal Abnormal
Upper limb: Shoulder, Wrist,
Orthopedic System Hands, Fingers Normal Abnormal
Lower limb: Hip, Ankle, Knee Normal Abnormal
Relaxes Normal Abnormal
Neurological System Verbal Responses Normal Abnormal
Motor Responses and balance Normal Abnormal
Asthma (Record) YES NO
Allergies Type of reaction(Record)
Medications used Name and dosage(Record) YES NO
QUESTION FOR ATHLETE TO BE ANSWERED BY THE PARENT YES NO REM
Is a doctor is currently treating you for anything?

Have you ever been unconscious or had a concussion?
Have you been hit hard in the head in the last 6 weeks?
Have you had any headache in the last 2 weeks?
Do you have any problem in bleeding?
Does any disease run in your family? Sudden unexpected death?
Have you had any surgery?
Have you ever had to stay in a hospital?
Name of Athlete: GAVILANGOSO, Jr., DANILO R. Fit to Play Not Fit to Pla
Signature Overprinted Name of Parent: DANILO, Sr. S. GAVILANGOSO SUSAN S. ROSALES
District Meet Date Examined: Regional Meet Date Examined:
0 0
Physician/Medical Officer Physician/Medical O
PRC Liscense PTR # PRC Liscense
Division Meet Date Examined: Palarong Pambansa Date Examined
0
XII
Region
COTABATO
Division
BALITE HIGH SCHOOL
School
School Address
CE CERTIFICATE OF COMPLETION
Date:

This is to certify that GAVILANGOSO, Jr., DANILO R.
has
o this date. the Grade/Year 11 (Elementary/Secondary Level) for the School Year
REY M. LANGC
School Head/R
(Signature Over Pr

10/01/2019
Date
of my/our son/daughter
in all School Sports Meets
from his/her participation in

erved to ensure his/her health
ollect, process, retain, and dispose

a Privacy Act of 2012.
AN S. ROSALES
other Over Printed Name
REY M. LANGCUBAN
School Head/Registrar
Signature Over Printed Name)
0/01/2019
DATE
MANENT TEETH
MENT NEEDS
SYMBOLS FOR ACCOMPLISHMENT

- EXTRACTED PERMANENT TOOTH
- EXTRACTED TEMPORARY TOOTH
- AMALGAM FILLING
- COMPOSITE FILLING
ARTIFICIAL RESTORATION
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- ZINC OXIDE UEGENOL FILLING
- TEMPORARY FILLING
- REFERRED TO PRIVATE DENTIST
- UNERUPTED TOOTH
REFERRED FOR DENTAL TREATMENT:

YES NO

YES NO

YES NO

YES NO
REMARKS
(FOR ANY ABNORMALITIES)
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
chool Year 2019-2020
Y M. LANGCUBAN
ool Head/Registrar
re Over Printed Name)
XII
Region
COTABATO
Division
Name: AÑOVER, NIÑA FE R. 10/01/2019

Age: 12 Sex: MALE Birth Date: 01/12/2003 DATE
Event: BILLIARD
Parent/Guardian: REYNALDO, S. AÑOVER RUBINA A. ROQUERO
CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPL

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANE
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORA
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATI
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVAT
UN - UNERUPTED TOOTH

0 WITH THIRD MOLAR: REFERRED FOR DENTAL T
DENTIST YES NO YES
DENTIST YES NO YES
DENTIST YES NO YES
WITH THIRD MOLAR: REFERRED FOR DENTAL T
DENTIST YES NO YES
OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
CIAL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED TOOTH
D FOR DENTAL TREATMENT:

NO
NO

NO

NO
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: QUIAO JESALYN

(Last) (First)
Sex: FEMALE Learner Reference Number (LRN) 130064110091 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 02/19/2005 Age: 14 Place of Birth: MATAS, POBLACION, MAGP
School: B.A. CALAMBA NATIONAL HIGH SCHOOL Grade Level 8
Address of School: PANGAO-AN, MAGPET,COTABATO
Present Address: PANGAO-AN, MAGPET, COTABATO
Parents: JUVIN J. QUIAO ELENA D. QUIAO
Address of Parents: 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
December 30, 1899 BILLIARD INTRAMURALS GOLD
December 30, 1899 BILLIARD UNIT MEET GOLD
December 30, 1899 BILLIARD MUNICIPAL GOLD
December 30, 1899 BILLIARD ZONE NONE
BILLIARD PROVINCIAL NONE
BILLIARD
QUIAO, JESALYN D.

Name and Signature of R
Sports Officer (RSO
(DSO)
ZONE MARITES A. AMANG EDMUND ROSETE SR. DR. MAGDALENA C. DUH
PROVINCIAL ARNEL L. MANOJO EDMUND ROSETE SR. DR. MAGDALENA C. DUH
0 0 EDMUND ROSETE SR. DR. MAGDALENA C. DUH

Screened by:
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Na
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: QUIAO, JESALYN D. Age: 14
Home Address: PANGAO-AN, MAGPET, COTABATO Gender: FEMALE

School: B.A. CALAMBA NATIONAL HIGH SCHOOL
School Address: PANGAO-AN, MAGPET,COTABATO
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
GAVILANGOSO, Jr., DANILO R. JUVIN J. QUIAO ELENA D. QUIA
Signature of Learner over printed name Signature of Parent/Guardian over printed nam

XII
Region
COTABATO
Division
Name: QUIAO, JESALYN D. Age: 14

Home Address: PANGAO-AN, MAGPET, COTABATO Gender: FEMALE
School: B.A. CALAMBA NATIONAL HIGH SCHOOL
School Address: PANGAO-AN, MAGPET,COTABATO
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
B.A. CALAMBA NATIONAL HIGH SCHOOL
School
PANGAO-AN, MAGPET,COTABATO
School Address
Date: 10/01/2019

This is to certify that QUIAO, JESALYN D.
0 0

CORD) DEPARTMENT OF EDUCATION
XII
Region
COTABATO
Division
School
School Address
PARENT'S CONSENT
D. I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) QUIAO, JESALYN D. in BILLIARD
BLACION, MAGPET
and safety.
QUIAO
rdian Further, I/We authorize the personnel of Department of Education to collect, proc
e below
Remarks
0 JUVIN J. QUIAO ELENA D. QUIA
0
0
NONE
GOLD
GOLD N/A
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: QUIAO, JESALYN D. 10/01/2019

Age: 14 Sex: FEMALE Birth Date: 02/19/2005 DATE
Event: BILLIARD
Parent/Guardian: JUVIN J. QUIAO ELENA D. QUIAO

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
ELENA D. QUIAO (√) - SOUND ERUPTED PERMANENT ZOE
ver printed name TOOTH TF
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
School
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

Name of Athlete: QUIAO, JESALYN D. Fit to Play Not Fit to Pla
Signature Overprinted Name of Parent: JUVIN J. QUIAO ELENA D. QUIAO
0 0
0
XII
Region
COTABATO
Division
School
School Address
E CERTIFICATE OF COMPLETION
Date:

This is to certify that QUIAO, JESALYN D.
has
his date. the Grade/Year 8 (Elementary/Secondary Level) for the School Year
0
School Head/R
(Signature Over Pr

10/01/2019
Date


NA D. QUIAO
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)
Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 12/30/1899 Age: 119 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
December 30, 1899 0 INTRAMURALS GOLD
December 30, 1899 0 UNIT MEET GOLD
December 30, 1899 0 MUNICIPAL GOLD
December 30, 1899 0 ZONE NONE
0 PROVINCIAL NONE
BILLIARD
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119
Home Address: 0 Gender: 0

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

This is to certify that ,
0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
0 I/We hereby willingly and voluntarily give consent to the participation of my/our so
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Age: 119 Sex: 0 Birth Date: 12/30/1899 DATE
Event: 0
Parent/Guardian: 0 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
0 (√) - SOUND ERUPTED PERMANENT ZOE
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

Name of Athlete: , Fit to Play Not Fit to Pla
Signature Overprinted Name of Parent: 0 0
0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
Mother Over Printed Name
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Address of School: BALITE, MAGPET, COTABATO
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth: 12/30/1899 119 0
(mm/dd/yyyy) Age: Place of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0
Signature of Learner over printed name Signature of Parent/Guardian over printed name

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
er printed name TOOTH TF
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD N/A
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: GAVILANGOSO, Jr. 0

16 (First)

Date of Birth:
Present Address: 0
Parents: 0 0
Address of Parents: BALITE, MAGPET, COTABATO

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
January 16, 1900 0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0
,

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar
Revised July 2019
XII
Region
COTABATO
Division
A. PERSONAL DATA:
Name: 0 0
(Last) (First)

Date of Birth:
Present Address: 0
Parents: 0 0

NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
NONE 0 0 0
0 PROVINCIAL NONE
0

Sports Officer (RSO
(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:

f) Chest pain.
g) Epigastric pain.
h) Back pain.
i) Sprain.
j) Fracture.
k) Seizure.
a) Cough
b) Colds
d) Diarrhea
e) Constipation
a) Mumps
b) Measles
c) Chicken pox
e) Other vaccines
, 0 0

XII
Region
COTABATO
Division
Name: , Age: 119

School: 0
School Address: 0
Date Accomplished:
Vital Signs

HEAD & NECK
CHEST & LUNGS
ABDOMEN
EXTREMITIES

WRIST 0/1/2/3 0/1/2/3
KNEE 0/1/2/3 0/1/2/3
MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5
0
LICENSE NO.
CONTACT NO.

XII
Region
COTABATO
Division
0
School
0
School Address
Date: 10/01/2019

0 0

XII
Region
COTABATO
Division
0
School
0
School Address
PARENT'S CONSENT
(M.I.) , in 0
0
and safety.
e below
Remarks
0 0 0
0
0
0
GOLD
GOLD 0
NONE
NONE 0 0
Adviser School Hea
lower meets.
Remarks:

0
0
Note:
__

XII
Region
COTABATO
Division
Name: , 10/01/2019
Event: 0

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

MALOCLUSSION xt
FLUOROSIS Am
FOR FILLING Gn -
NORMAL Com
MODERATE GINGIVITIS
R
UN

0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
0 WITH THIRD MOLAR:
DENTIST YES NO
WITH THIRD MOLAR:
DENTIST YES NO
XII
Region
COTABATO
Division
0
School
0
School Address
MEDICAL CERTIFICATE

___________________

REMARKS
Head
Breath sound, Rib

Normal Abnormal

0 0
0
XII
Region
COTABATO
Division
0
School
0
School Address
Date:

has
0
School Head/R
(Signature Over Pr

10/01/2019
Date


0
0
0/01/2019
DATE
MANENT TEETH
MENT NEEDS

- AMALGAM FILLING
- COMPOSITE FILLING
- JACKET CROWN
- INLAY
- ORAL PROPHYLAXIS
- TEMPORARY FILLING
- UNERUPTED TOOTH

YES NO

YES NO

YES NO

YES NO
REMARKS
REMARKS BY PARENT
Not Fit to Play
xamined:
0
n/Medical Officer
PTR #
te Examined:
n/Medical Officer
PTR #
has completed
0
ool Head/Registrar

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REPUBLIC OF THE PHILIPPINE

RONALD S. RAMONES-KIDAPAWAN CITY

PARENTAL CONSENT MUST BE SIGNED BY MOTHER AND

1 2019 XII MAPSSAA BILLIARD GAVILANGOSO, Jr. DANILO R.

Participation to previous Palarong Pambansa

MALE 5/15/1970 TEMPORAN NATIONAL HIGH SCHOOLPUBLIC TEMPORAN,MAGPET,COTABATO COTABATO

Athletic Meet REMARKS Remarks-PARENTAL CONSENT (A1) Remarks-PARENTAL CO

Remarks-PARENTAL CONSENT (A3) Remarks-PARENTAL CO

Remarks-PARENTAL CONSENT (A4) Remarks-PARENTAL CO

130074080014 BALITE, MAGPET, COTABATO DANILO, Sr. S. GAVILANGOSO

N/A MAKILALA, COTABATO ISARIO P. ALCALAYDE

304465 N/A SILAY CITY NEGROS OCCIDENTALWILFREDO G. MANOJO

Remarks-PARENTAL CONSENT (A6) Remarks-PARENTAL CONSENT (A11)

Remarks-PARENTAL CONSENT (A7) Remarks-PARENTAL CONSENT (A12)

Remarks-PARENTAL CONSENT (A8) Remarks-PARENTAL CONSENT (A13)

Remarks-PARENTAL CONSENT (A9) Remarks-PARENTAL CONSENT (A14)

SUSAN S. ROSALES NONE N/A

MARIA B. ALCALAYDE NONE N/A

AURORA D. LUSADA NONE N/A

ONSENT (A11) Remarks-PARENTAL CONSENT (A16)

ONSENT (A12) Remarks-PARENTAL CONSENT (A1)7

ONSENT (A13) Remarks-PARENTAL CONSENT (A18)

BALITE, MAGPET,COTABATO BALITE, MAGPET, COTABATO 11

BALITE, MAGPET,COTABATO POBLACION, MAGPET, COTABATO N/A

APO SANDAWA HOLMES PHASE 1 APO SANDAWA HOLMES PHASE 1

ks-PARENTAL CONSENT (A16)

ks-PARENTAL CONSENT (A1)7

ks-PARENTAL CONSENT (A18)

MAGENTA ROLAND C. MAYA REY M. LANGCUBAN 2019-2020 07/28-29/2019

N/A N/A REY M. LANGCUBAN 2019-2020 07/28-29/2019

N/A N/A ARNI B. BALEÑA 2019-2020

UNIT MEET MUNICIPAL MEET ZONE MEET

09/23 - 24/2019 10/07-08/2019 NONE

MAGPET 10/07-08/2019 NONE

NONE NONE 9677185157

NONE NONE 9677185157

COACH/ASST. COACH/CHAPERON RECORD

CONTRACT OF SERVICE (FOR PRIVATE)

AMANG, MARITES A. NAME ,

COACH/ASST. COACH/CHAPERON RECORD

CONTRACT OF SERVICE (FOR PRIVATE)

MANOJO, ARNEL L. NAME

GAVILANGOSO, Jr., DANILO R. NAME OF ATHLETE QUIAO, JESALYN D.

AÑOVER, NIÑA FE R. NAME OF ATHLETE ,

AR-I (ATHLETE RECORD)

Name: GAVILANGOSO, Jr. DANILO

Year of Participation Sports Event Venue Remarks

Name and Signature of

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Name: GAVILANGOSO, Jr., DANILO R. Age: 16

Home Address: BALITE, MAGPET,COTABATO Gender: MALE

MEDICAL EXAMINATION FORM

Republic of the Philippines

Name: GAVILANGOSO, Jr., DANILO R. Age: 16

REVIEW OF SYSTEMS NO ABNORMALITIES WITH ABNORMALITIES REMARKS

Pupils equally reactive to light and accommodation: YES NO

KNEE 0/1/2/3 0/1/2/3