Physical Examination Certificate

Name

YassineSabek

SexF

Age29

Dateofbirth1986/10/06

AddressAvenueFAR.ResidenceHatim748

Tel:2.12624E+11

1
Pleasecheckifyouhavehadanyofthefollowingdiagnosis.

tuberculosis

typhoidfeverparatyphoidfever

gastricandduodenalulcer

hepatitis

heartdisease

measles

asthma

diabetes

poliomyelitis

Dysentery

nervedisorder

cancerleukemiamalignanttumor

highbloodpressure

psychosis

Pleaselistanyoperations,fractures,ormajorinjuriesyouhavehadinthepast,andtheage.

2.

Heightcm

Weight

kg

EyesightRL

Bloodtype

Colorvision

HearingRL

Eyedisease

Nose,ear,andthroatdisorder

Date

Xray

Result:NormalNeedcloseexaminationNeedmedicaltreatment

3.
Idiagnosethattheapplicantshealthandphysicalconditionis:

Excellent

Good

Fair

Poor

4.
Doyouthinktheapplicantsphysicalconditionisgoodenoughforhim/hertostudyinJapan?

Yes

No

Otherremarks


Iherebycertifytheabovestatementsareaccurate.

Signature
Nameofphysician
Address
Date

SokaUniversity