O C A C , Republic of China (Taiwan)

Name in Chinese

Items Required For Health Certificate 3 Valid for Three Months

Date of Examination (D) (M) (Y) Attach One Recent 1-inch Photo Here

Name in English:

Sex

Male Date of Birth

Female
/ /

Passport No Nationality

PHYSICAL EXAMINATION
A. B. C. D. E. F. Height Pulse Blood pressure Heart Locomotors Hernia
/

cm
/

time / min
mm Hg

G. H.

Weight Vision Abnormal Abnormal Abnormal

Right

Kg / Lb Left

Normal Normal Normal

LABORATORY EXAMINATIONS

A. B. Chest Hepatitis

Application missing this information will not be accepted.

-Ray for Tuberculosis Surface Antigen Normal Positive Abnormal Negative

MEDICAL HISTORY

A. B. C. D. Heart disease Asthma Hypertension Diabetes

Have you ever had the following diseases Yes No E. Epilepsy Yes Yes Yes No No No
/

Yes Yes Yes Yes

No No No No

F. G. H.

Kidney disease Malaria Liver Disease

/

CONCLUSIONAbove is the medical report of Mr. / Ms

He / She

Is

Is not fit

Hospitals or Clinics Name, Address and Telephone

Chief Physician
Name & Signature

Date

(D)

(M)

(Y)

Superintendent
Name & Signature