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
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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.
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4. Lungs
5, Heart condition
6. Blood pressure
7. X-rays of lungs
8. Urine Analysis
Sugar_/
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10. vim ea lov) Blood grove = OV:
‘Trachoma and other progressive eye disease
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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
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