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  • Certi FI Cateofhealth: Sur Name

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    1. This document is a certificate of health completed by an examining physician in 2021. It includes information from a physical examination such as height, weight, blood pressure, pulse, eyesight, hearing, etc. It also documents the results of a chest x-ray and any current or past illnesses. 2. Laboratory tests results are included for urine analysis, anemia testing, liver function tests, and any other impressions or notes from the examining physician. 3. In summary, this certificate of health comprehensively documents the results of a medical examination to assess an individual's overall health status.

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    1. This document is a certificate of health completed by an examining physician in 2021. It includes information from a physical examination such as height, weight, blood pressure, pulse, eyesight, hearing, etc. It also documents the results of a chest x-ray and any current or past illnesses. 2. Laboratory tests results are included for urine analysis, anemia testing, liver function tests, and any other impressions or notes from the examining physician. 3. In summary, this certificate of health comprehensively documents the results of a medical examination to assess an individual's overall health status.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    16 views2 pages

    Certi FI Cateofhealth: Sur Name

    Uploaded by

    NK production
    1. This document is a certificate of health completed by an examining physician in 2021. It includes information from a physical examination such as height, weight, blood pressure, pulse, eyesight, hearing, etc. It also documents the results of a chest x-ray and any current or past illnesses. 2. Laboratory tests results are included for urine analysis, anemia testing, liver function tests, and any other impressions or notes from the examining physician. 3. In summary, this certificate of health comprehensively documents the results of a medical examination to assess an individual's overall health status.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    CERTI

    FICATEOFHEALTH
    (tobecompl
    etedbyt
    heexami
    ning
    physi
    ci
    an) 2021

    Nam Gi
    venname Mi
    ddl
    ename
    e Sur
    name
    □ Mal e
    Gender □ Femal
    e Dat
    eofBi
    rt
    h
    y
    yyy mm dd

    １．
    Physi
    calexaminat
    ion
    (
    1) cm (
    2) kg
    Height Weight
    (
    3) mmHg～ ( 4) □A □B □RH ＋
    Bl
    oodpressure mmHg Bl oodtype □AB □O □RH－
    (
    5) □ Regular (
    7) □ Nor
    mal
    Pul
    se □ I
    rregular Colorbli
    ndness □ I
    mpair
    ed
    () (
    8) □ Nor
    mal
    (
    )Wit
    houtgl
    asses (R) Hearing □ I
    mpair
    ed
    (
    L)
    (6)
    Eyesi
    ght
    (右) (
    9) Speech □ Nor
    mal
    (
    ) □ I
    mpair
    ed
    Wit
    hglassesorcontactl
    enses(R)
    (
    L)
    ２． （６）
    Phy
    sical
    andX- r
    ayexaminati
    onsoft hechest (wi
    thi
    nsixmont
    hs)
    .
    Descr
    ibet
    hecondi
    ti
    on Dat
    eofX-
    ray y
    yyymm dd
    ofl
    ungs.

    Fil
    m No.
    (
    1) □ Normal
    Lungs □
    Impai
    red
    (
    2) □
    Car
    diomegal
    y
    Nor
    mal
    □ I
    mpai
    red

    □ Nor mal
    I
    fimpair
    ed⇒El
    ect
    rocar
    diogr
    aph□
    I
    mpaired
    ３. □ No□ Yes： Di
    sease
    Diseasecurr
    ent
    lybei
    ng
    t
    reated
    ４．
    Past Dat e of Dat e of
    i
    ll
    ness/di
    sorder recovery recover
    ✔ ✔ Name y
    Name /under
    t
    r eatment /under
    treatme
    nt

    Pleasecheckandf il
    li
    n Tuber
    cul
    osi
    s Mal
    ari
    a
    thedat eof
    recov er
    y/under Other Epi
    l
    epsy
    treatment. communicabl
    e
    I
    fNOTcont ractedany di
    sease
    oft hem i
    nt hepast,
    pleasecheck“ None”. Ki
    dney Hear
    tdi
    sease
    di
    sease

    Di
    abet
    es Dr
    ugal
    l
    ergy
    ✔ None Psy
    chosi
    s Funct
    ional
    di
    sorderint
    he
    ext
    remiti
    es
    ５．
    Laborat
    orytest
    s
    (1)
    glucos pr
    otei
    n occu
    Uri
    nal
    ysis e lt
    : bloo
    d
    (
    2) mm/
    Hr /
    cmm gm/
    Anemia ESR WBC Hemogl
    obi
    n dl Anemi
    a
    test count
    (
    3) GPT （I
    U/ｌ） GOT （I
    U/ｌ） γ- （I
    U/ｌ）
    LFT （ALT) （AS GTP
    T)
    ６．
    Physi
    cian'
    simpr
    essi
    onoft
    heappl
    icant
    ’s
    heal
    th
    。
    Pl
    easefil
    li
    niftheappl
    i
    cantneedsr
    egul
    ar
    medicat
    ionortr
    eatment
    .

    Dat
    e

    Physi
    cian'
    s
    Si
    gnature

    Off
    ice/
    Inst
    it
    ut
    i
    on

    Addr
    ess

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