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    Sulistyo Gulo
    1. This document appears to be a template for a certificate of health to be filled out by an examining physician. 2. It requests information such as the applicant's name, date of birth, results of a physical examination checking boxes for normal or impaired conditions of movement, speech, vision, and hearing. 3. It also requests details of a chest x-ray examination from within the last 6 months and any present or past diseases or disorders. 4. The physician is asked to check a box indicating if the applicant's health status is adequate to study in Japan based on their medical history and examination findings.

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    Format MCU

    Uploaded by

    Sulistyo Gulo
    9 views1 page
    1. This document appears to be a template for a certificate of health to be filled out by an examining physician. 2. It requests information such as the applicant's name, date of birth, results of a physical examination checking boxes for normal or impaired conditions of movement, speech, vision, and hearing. 3. It also requests details of a chest x-ray examination from within the last 6 months and any present or past diseases or disorders. 4. The physician is asked to check a box indicating if the applicant's health status is adequate to study in Japan based on their medical history and examination findings.

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    Mamsmsmsms

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    1. This document appears to be a template for a certificate of health to be filled out by an examining physician. 2. It requests information such as the applicant's name, date of birth, results of a physical examination checking boxes for normal or impaired conditions of movement, speech, vision, and hearing. 3. It also requests details of a chest x-ray examination from within the last 6 months and any present or past diseases or disorders. 4. The physician is asked to check a box indicating if the applicant's health status is adequate to study in Japan based on their medical history and examination findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    9 views1 page

    Format MCU

    Uploaded by

    Sulistyo Gulo
    1. This document appears to be a template for a certificate of health to be filled out by an examining physician. 2. It requests information such as the applicant's name, date of birth, results of a physical examination checking boxes for normal or impaired conditions of movement, speech, vision, and hearing. 3. It also requests details of a chest x-ray examination from within the last 6 months and any present or past diseases or disorders. 4. The physician is asked to check a box indicating if the applicant's health status is adequate to study in Japan based on their medical history and examination findings.

    Copyright:

    © All Rights Reserved
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    of 1

    LPK SAKURA BINA CITA

    ' Raya Puncak KM.77 { Jembatan Limalang}, Desa Kopo, Cisarua - Bogor
    Jl.
    ' Telp. (0251182971.39, Email: s$Ega--b6ffijj[1i=-q.0jd
    Training Center : Asrama SMK l(esehatan Al-lkhlas, Jl. Hankam, Desa Jogjogan, Kec. Cisarua, Kab. Bogor 16150

    &*ffi EA ffi * rrag et: "k tJ EeA)


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

    HEEI;ALJ6fi6El:;196,5;t. ptease fill out (f,nfutffwE) in English.


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    I{ame: Date of birth:
    t. ${t*^iE {a*,*t Afr *f zv?}
    Pltysical condiiion (Please check one box.)

    (t) iE s: rEH Normal (a) E eE niEH Normal


    Movetient "*H Impaired Speecli uEH Llrpaired
    (z) tH H uEH Normal $) ?@+'b orher findings
    Vision rHH Impaired e{6H{ft64Eil,,1.Lr<ff*r,r
    Please cl*scritre the deiails.
    {3) ffi H nEHNormal
    Hearing r&H hnpairerl
    2. f;8*tr x *#+fr6 (a nHp,rffit:tf&)
    Chest X-ray examination (Eecord within 6 months)
    Bt -8, Describe the concl.ition of lungs
    nr\
    l. HtfE#
    Fasi diseas*/disorder
    LJU
    IffiF'E
    Date_ __
    4. !n ffi Present
    disease/drsorder

    i.,Bffi * o 8*&#, aa#, ffi 6 0 #f; * *' 6*rI ffi L( " ffi & {D &*ffi fi :fi, {t Et * B # ;*
    t
    /, ffi i.i.6+,0 &
    B*:*l*f *1" (Efi g f 6 fi ** w C)
    ln view of the appl-icant's rnedical history and the abol.e fi.ndings, is it your observation that
    'ris/her heaith status is adequate to study in Japan? (please check one box.)
    rl*Lr Yes r::LiLr.i- No
    EI{* #&
    Date: $ignature:

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    \tarne of P n in Print
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    \ddress

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