CERTIFICATE OF HEALTH (to be completed by the examining physician)

Please fill out (PRINT/TYPE) in Japanese or English.

Name:

Family name,

First name

Male
Female

Middle name

Date of Birth:

Age:

Physical Examination
(1)
Height

cm

Weight

(2)
Blood pressure

kg

mm/Hg

(3)
Eyesight: (R)
(L)
Without glasses
(4)
Hearing:

mm/Hg

Blood type

(R)
(L)
With glasses or contact lenses

normal
impaired

Speech:

A B O RH

regular
Pulse irregular
normal
impaired

Color blindness

normal
impaired

)
Please describe the results of physical and X-ray examinations of the applicant's chest x-rays (X-rays taken more than 6 months prior
to this certification are NOT valid).

normal
Cardiomegaly: impaired

Date

Film No.
Electrocardiograph : normal
impaired
Describe the condition of applicant's lungs.

Lungs:

normal
impaired

Under medical treatment at present

Yes (Conditions/particulars:
No

Past history : Please indicate with or and fill in the date of recovery
Tuberculosis......( . .
)
Malaria.......( . . )
Other communicable disease......(
Epilepsy......( . . )
Kidney disease.....( . . )
Heart disease......( . . )
Diabetes......( . . )
Drug allergy......( . . )
Psychosis.....( . . )
Functional disorder in extremities......( . . )
Laboratory tests
Urinalysis: glucose (
ESR:
Hemoglobin:

), protein (

), occult blood (

mm/Hr, WBC count:

gm/dl, GPT:

/cmm

anemia

YesNo

In view of the applicant's history and the above findings, is it your observation that his/her health status is adequate to pursue studies in Japan?

Yes

No

Particulars or additional comments:

Date:

Signature:

Physician's Name (Print):

Office/Institution:

Address: