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Certificate of Health: Surname

This document is a certificate of health completed by an examining physician. It includes sections for physical examination results such as height, weight, blood pressure, eyesight, hearing, and chest x-ray findings. It also documents any current or past illnesses, laboratory test results, and the physician's overall impression of the applicant's health. Fields are provided for the physician's signature, office/institution, and address.

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510 views2 pages

Certificate of Health: Surname

This document is a certificate of health completed by an examining physician. It includes sections for physical examination results such as height, weight, blood pressure, eyesight, hearing, and chest x-ray findings. It also documents any current or past illnesses, laboratory test results, and the physician's overall impression of the applicant's health. Fields are provided for the physician's signature, office/institution, and address.

Uploaded by

NK production
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as ODT, PDF, TXT or read online on Scribd
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CERTIFICATE OF HEALTH

(to be completed by the


examining physician)

Given name Middle name


Name Surname 　　　 　　
□ 　Male 　　　　
Gender □ Female Date of Birth 　　　　　　　　　　 yy
yy mm dd

１．
Physical examination
(1) cm (2) kg
Height Weight
(3) mmHg～　　　　　　　mmHg (4) □A　□B　 □RH ＋
　Blood pressure Blood type □AB　□O □RH－
(5) □ 　Regular (7) □ 　Normal
　Pulse □ 　Irregular 　Color blindness □ 　Impaired
　　 　 　　 ()　　 　 　 　() (8) □ 　Normal
Without glasses　　 (R) 　　　 　 　Hearing □ 　Impaired
(6) (L)
Eyesight 　　　　　　 　 (右)　　 　() (9)　Speech □ 　Normal
With glasses or contact lenses (R) □ 　Impaired
(L)
２．　（６）
Physical and X-ray examinations of the chest　(within six months)
　 .
Describe the condition Date of X-ray yyyy mm dd
of lungs.

Film No.
(1) □ 　Normal
　Lungs □
　Impaired
(2) □
　Cardiomegaly 　Normal
□ 　Impaired

□ 　Normal
If impaired⇒Electrocardiograph □ 　
Impaired
３. □　　No □　　Yes ：　　Disease
　　Disease currently being
treated
４．
　　Past illness/disorder Date of Date of
✔ Name recovery /under ✔ Name recovery /
treatment under
treatment

Please check and fill in the Tuberculosis Malaria


date of recovery/under
treatment. Other Epilepsy
If NOT contracted any of communicable
them in the past, please disease
check “None”.
Kidney disease Heart disease

Diabetes Drug allergy

✔ None Psychosis Functional


disorder in the
extremities
５．
Laboratory tests
(1)
　 glucos protein occult
Urinalysis: e blood
(2) mm/Hr /cmm gm/dl
Anemia test ESR WBC Hemoglobin Anemi
count a
(3) GPT （IU/ｌ） GOT （IU/ｌ） γ-GTP （IU/ｌ）
　　LFT （ALT) （AST
)
６．
Physician's impression of the applicant’s
health
　。
Please fill in if the applicant needs regular medication or
treatment.

　 Date

Physician's
Signature

Office/Institutio
n

Address

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