Quezonian Educational College Inc. Quezonian Educational College Inc.

INDIVIDUAL RECORD FORMS

MEDICAL CLEARANCE FORM (Physical Fitness Pre-Testing)
(To be accomplished by the school physician prior to the testing period)
Note : Medical clearance form is required.
INDIVIDUAL RECORD FORMS
NOTE: This form should be submitted by the student before administering the (Pre-test)
Physical Fitness Test.

This is to protect the teacher from being blamed for any accident such NAME _________________________________________ Group No. ___________
as fainting, injuries and the like.
Test Items Results/Score

Test # 1
___________________ Standing Long Jump __________________
Date
Test # 1
Name _______________ College ___________ Course/Major __________________ Bent- Knee Curl Up __________________

Sex ______ Age _______ Height _________ centimeters Weight _______ kilogram Test # 3
50 Meter Sprint __________________

Test # 4 (Males)
This individual is Physically [ ] able
Regular Push Up __________________
[ ] not able
Test # 5
to participate in physical education class activities and physical fitness testing. Knee Push Ups __________________

Test # 6
Shuttle Run __________________

_________________________ Test # 7
Examining Physician Sit and Reach __________________

Noted : Test # 8
1000 Meter Run __________________

_________________________ Test # 9
3 Minute Step Test __________________
PE Instructor
Pulse Count : ________
PEI ________________