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MEDICAL CERTIFCATE N.B/F SPACE 1S INADEQUATE PUB. SERVICE ee USE THE BACK SIDE AME |S wae\ Tp yahim ADDRESS, 1. Diseases in the past (if any ) 1. if hospitalized , indicate period and of hospitalization (ey Teertify the above statement are complete and true SS enol 20ee Signature -Date ‘The doctor's examination (insert x in appreciate space ) 3. THE GENERAL STATUS AND CONDITION OF PAIENT 2. (e® 4. Lungs 5, Heart condition 6. Blood pressure 7. X-rays of lungs 8. Urine Analysis Sugar_/ eet dN Red ceits Aovrwat white cetis Alpvurot 10. vim ea lov) Blood grove = OV: ‘Trachoma and other progressive eye disease at, 9 ¥ ey 2 Wteale 11. Ear (able to hear normal voice at 4meters) Le. to heon wg 12, Serological Exam, Syphilis abe 13Neurological examination - A) Symptom of disturbance nervous System _b) Mental status 9. Het 14, Final Seat of date of the doctor Ato/Wt Has been medically Serr in accordance with the above outline and he/she is medically Employment Doctor's Sit Date — B\-0f- Zoay Scanned with CamScanner

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