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

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

Name:

Family name,

First name

Middle name

Male
Female

Date of Birth:

Physical Examination
(1)
Height

cm

Weight

(2)
Blood pressure

kg

mm/Hg

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

mm/Hg

Blood Type

(R)
(L)
With glasses or contact lenses

Normal
Impaired

Speech:

A B O RH

Pulse

Regular
Irregular

Normal
Color blindness Impaired

Normal
Impaired

)
Please describe the results of physical and X-ray examinations of the applicant's chest X-rays (X-rays taken more than six months prior
to the certification are NOT valid).

Normal
Cardiomegaly: Impaired

Date

Film No.
Electrocardiograph : Normal
Impaired
Describe the condition of applicant's lungs.

Lungs:

Normal
Impaired

Yes (Disease
No

Disease currently being treated

Past history : Please indicate with or and fill in the date of recovery
(If the applicant has not contracted any of the disease, please chech None.)
Tuberculosis......( . .
)
Malaria.......( . . )
Other communicable disease......(
Epilepsy......( . . )
Kidney disease.....( . . )
Heart disease......( . . )
Diabetes......( . . )
Drug allergy......( . . )
Psychosis.....( . . )
Functional disorder in extremities......( . . )

None.....
Laboratory tests
Urinalysis: glucose (
ESR:

), protein (

), occult blood (

mm/Hr, WBC count:

Hemoglobin:

gm/dl, GPT:

/cmm

anemia

Please give your impression of the applicants health. (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:

Signature:

Physician's Name in Print :

Office/Institution:

Address: