MINISTRY OF RESEARCH, TECHNOLOGY, AND HIGHER EDUCATION

YOGYAKARTA STATE UNIVERSITY

FACULTY MATHEMATICS AND NATURAL SCIENCES
Colombo Street, No.1, Yogyakarta 55281, Indonesia
Telepohone: +62 274 586168, Ext.1217, Fax:+62 274 548203
Website: http//fmipa.uny.ac.id, E-mail: humas_fmipa@uny.ac.id

MEDICAL CERTIFICATE

PERSONAL DATA

1. Name of Applicant :.....................................................................................................

2. Date of Birth :.....................................................................................................
3. Permanent Address :.....................................................................................................
Country :............................... District :.........................................
Province :............................... Postal Code :.........................................
City :...............................

PREVIOUS MEDICAL RECORD

4. Candidate’s medical history: congenitial or acquired disability
..........................................................................................................................................
a) Chronic condition: diabetes, asthma, hypertension, rheumatis, allergy,
psychiatric, neurological, other
...................................................................................................................................
b) Medication (temporary/longstanding)
...................................................................................................................................
c) Hospitalization, date, diagnosis
...................................................................................................................................
5. Family diseases................................................................................................................
6. Other Information.............................................................................................................

MEDICAL EXAMINATION
7. Height...................................................... Weight..................................................kg
8. Blood pressure......................................... Pulse........................................per minute
9. Vision.................. Glasses/correction................Rt............Lt............Colours...................

CONCLUSION
On the basis of a medical examination, I certify that Mr/Ms.......................................................
born on.........................., ................................. is in good/bad health.

Date..................................... Doctor’s signature and stamp......................................................