2013

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

Please fill out (PRINT/TYPE) in Japanese or English. Name: , Male Female Date of Birth: Age:

Family name,

First name

Middle name

Physical Examination (1) Height (2) Blood pressure cm Weight mm/Hg kg mm/Hg Blood type A B O RH regular Pulse irregular normal impaired

(3) Eyesight: (R) (L) Without glasses (4) Hearing: normal impaired

(R) (L) With glasses or contact lenses Speech: normal impaired

Color blindness

) Please describe the results of physical and X-ray examinations of the applicant's chest x-rays (X-rays taken more than 6 months prior to this certification are NOT valid). normal Cardiomegaly: impaired Date Film No. Electrocardiograph : normal impaired Describe the condition of applicant's lungs. Lungs: Under medical treatment at present Yes (Conditions/particulars: No ) normal impaired

Past history : Please indicate with or and fill in the date of recovery Tuberculosis......( . . ) Malaria.......( . . ) Other communicable disease......( Epilepsy......( . . ) Kidney disease.....( . . ) Heart disease......( . . ) Diabetes......( . . ) Drug allergy......( . . ) Psychosis.....( . . ) Functional disorder in extremities......( . . ) Laboratory tests Urinalysis: glucose ( ESR: Hemoglobin: ), protein ( ), occult blood ( /cmm ) . . )

mm/Hr, WBC count: gm/dl, GPT:

anemia

YesNo 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

Particulars or additional comments:

Date:

Signature: Physician's Name (Print): Office/Institution: Address: