fy) LEK IFICATE OF HEALTH SZ sormaeNivEnsiTy 7H Kioicho Cj Tokyo 12-6555, Gincore, NOW _) cuit Blonte NOSOMIF_y ’fwo Rist 72160 a 60-5 ‘witht glass or contact les ith glasses or contact enses 2 Please describe the results of physical and X-ray examinations of the applicant’ chest xrays. ‘All applicants are required to have X-ray examination taken within 6 months before the application deadline. Casionety rama! a ~ Ol impaired Ub dette emma imo (EISSARNG - ; on Deseo of pcan sng {ilar erent ent Yes amore: ‘No 4. Past history: Please indicate with A (recovered fully), B (receiving follow-up care) or C (under treatment at present). Name fies || Nameof les | Anemiablood disease ( = Tieiiecgts (ey Se ene ‘Tinnwid disease (=X 2 CL a has earn 7 Sys ayo") Thereby certify that the above information is comect, and this student does not have any medical problems to ssudy abroad, ae: (G flo (U1 ir des Mee oinawosticcinti® ae seme “4