CERTIFICATE OF HEALTH

(to be completed by the examining physician)

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

Name Family name Given name Middle name
Male
Sex Female Date of Birth Year Month Day

Physical examination
(1) (2)
cm kg
Height Weight
(3) (4)
mmHgmmHg ABABO RHRH
Blood pressure Blood type
(5) Regular (7) Normal
Pulse Irregular Color blindness Impaired
() () (8) Normal
Without glasses (R) (L) Hearing Impaired
(6)
Eyesight
() () (9) Normal
With glasses or contact lenses (R) (L) Speech Impaired

Physical and X-ray examinations of the chest(within six months)

X
Describe the condition of lungs. Date of X-ray Year Month Day

Film No.
(1) Normal
Lungs Impaired
(2) Normal
Cardiomegaly Impaired
Normal
If impairedElectrocardiograph Impaired

No Yes Disease
Disease currently being treated
/ /

Name

Date of recovery Name

Date of recovery
Past illness/disorder /under treatment /under treatment

/
Tuberculosis Malaria

Other communicable disease Epilepsy

Please check and fill in the date of
recovery/under treatment. Kidney disease Heart disease
If NOT contracted any of them in the
past, please check None. Diabetes Drug allergy


Functional disorder in the
None Psychosis extremities

Laboratory tests
(1)
Urinalysis: glucose protein occult blood
(2)
mm/Hr /cmm gm/dl
Anemia test ESR WBC count Hemoglobin Anemia
(3) GPT GOT
IU/ IU/ -GTP IU/
LFT ALT) AST)

Physician's impression of the applicants health

Please write if the applicant needs regular medication or
treatment. If you do not have a particular opinion, please write as
such.

.
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

Date Year Month Day Physician's Signature

Office/Institution Address