HA NOI HEALTH DEPARTMENT SOCIALIST REPUBLIC OF VIET NAM

HONG DUC MEDICAL TECHNOLOGY JSC Independence - Freedom - Happiness

VIETNAM - KOREA CLINICS

No: …. /GKSK-SYTHN

HEALTH CERTIFICATE
Full name (CAPITAL LETTER): ………….…………..………………………...…...

Photo Gender:           Male       □ Female        □ Age:............................

(4 x 6 cm) ID or passport number: .....................…............ Date of issue........./……../..........
Issued by…………………………………………………………………………………
Permanent Residence:………………………….………………….......................……..
………………….................…...…………............……….....…………….……...…
Address: ........................................................................................................
Reason of health examination: ........................................................................

MEDICAL HISTORY
1. Family medical history:
Has anyone in your family suffered from one of diseases?: contagious disease,
cardiovascular disease, diabetes mellitus, tuberculosis, bronchial asthma, cancer, epilepsy,
psychiatric illness, others:
a) No □; b) Yes □;
If “Yes”, please specify the disease:……………………………................…..........………
…………………………………………………..………………………………………………
2. Personal medical history:
Have you ever suffered/Are you suffering from the following diseases?: contagious
disease, cardiovascular disease, diabetes mellitus, tuberculosis, bronchial asthma, cancer,
epilepsy, psychiatric illness, others:
a) No □; b) Yes □;
If “Yes”, please specify the disease:……………………………................…..........………
…………………………………………………..………………………………………………

3. Other questions (if have):

a) Are you receiving treatment for any disease? If yes, please list any prescribed pills and
dosages you are taking:
………………………………………………………………………………………………….
…………………………………………………..…………..………….…………………….
….......................................................
b) Pregnancy history (For women): …………………………………………………….............................
………………………………………………………………………………….………………..........................

I hereby declare that the above Ha Noi, day .......... month........ year .............
statements are true to the best of
 my knowledge. Proponent
(Signature and full name)
I. PHYSICAL EXAMINATION

Height:  ...............................cm; Weight: ........................ kg;    BMI index: ..............................

Pulse: .............................beats/minute; Blood pressure:.................... /..................... mmHg  
Classification of physical strength:.........................................................................................................................................................
II. CLINICAL EXAMINATION

Examination content Full name and

signature of doctors
1. Internal medicine: ......................................
a) Circulation system: ............................................................................................................................ ......................................
Classification ............................................................................................................................................. ......................................
b) Respiratory system: ........................................................................................................................... ......................................
Classification ............................................................................................................................................. ......................................
c) Gastrointestinal system: ............................................................................................................. ......................................
Classification ......................................................................................................................................... ......................................
d) Kidneys and urinary system: .................................................................................................. ......................................
Classification ........................................................................................................................................... ......................................
e) Musculosketal system: .................................................................................................................. ......................................
Classification ............................................................................................................................................ ......................................
f) Nervous system: ................................................................................................................................... .....................................
Classification .......................................................................................................................................... ......................................
g) Mental system: ..................................................................................................................................... .....................................
Classification .............................................................................................................................................. ......................................
2. External medicine: ...................................................................................................................... ......................................
Classification ............................................................................................................................................. ......................................
3. Obstetrics and gynecology: ............................................................................................... .....................................
Classification................................................................................................................................................... ......................................
4. Eye: .....................................
- Results: Without glasses: Right eye:............. Left eye: .................... ......................................
With glasses:       Right eye:............. Left eye: .................... .....................................
- Diseases of eye (if have): .......................................................................................................... ......................................
- Classification: ...................................................................................................................................... .....................................
5. Ear-Nose-Throat ......................................
- Results of hearing examination: .....................................
Left ear:  Normal speech:.......................... m;    Wispering speech:..................m ......................................
Right ear:  Normal speech:.........................m;    Wispering speech:..................m ......................................
- Diseases of ear-nose-throat (if have):……....................................……….….......… ......................................
- Classification: ......................................................................................................................................... .....................................
6. Tooth-Jaw-Face ......................................
- Results: + Upper jaw:.......................................................................................................... ......................................
+ Lower jaw: ....................................................................................................... ......................................
- Diseases of tooth-jaw-face (if have)............................................................................. ......................................
- Classification:.......................................................................................................................................... ......................................
7. Dermatology: ..................................................................................................................................... ......................................
................................................................................................................ ......................................
 Examination content Full name and
signature of doctors
Classification:................................................................................................................................................. ......................................

III. SUBCLINICAL EXAMINATION

Full name and

Examination content signature of
doctors
1. Test of hematology:
a) Complete blood count: Erythrocyte count: ................................................... ................................
Leukocyte count: ............................... Platelet count:.......................................... ...............................
b) Analyses: Glucose: ............................................................................................ ................................
Urea:..................................................................... Creatinine:......................................................... ...............................
ASAT (GOT):.......................................... ALAT (GPT): .................................................. ................................
................................
c) Others (if have): HIV : HBsAg: ................................
................................
d. Blood group: ................................

2. Test of urine:
a) Glucose: ............................................................................................................................................... ................................................
b) Protein: ............................................................................................................................................. ................................................

................................................
c) Others (if have): HEROIN : HCG: ...............................................

3. Image Diagnostic: ................................................

..........................................................................................................................................................................
................................................
..........................................................................................................................................................................
................................................

IV. CONCLUSION

1. Classification of health:......................................................................................................................................................................
2. Diseases (if have): ......................................................................................................................................................................
...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................

Hà Nội, date…… month…… year ..........

DOCTOR
(Full name, signature and seal)