英文健康体检表CERTIFICATEOFHEALTH

1、健康断害CERTIFICATEOFHEALTHPleasefillout(PRINT/TYPE)inJapaneseorEnglish.氏名生年月日Name,DateofBirth:FamilynameFirstname,Middlename口男Male/安FemalepplicantPleaseanswerthequestionsbelowbeforesubmittingtoaphysicianforyourphysicalexamination.1.谩去5年以下内病家35己1/、：大舌玄病IO二力、力、二占力35m舞E入Pleasecheckthelistofdiseasesbelowan

2、d/orspecifyifyouhavehadinthepastfiveyears.Asthma余吉核TuberculosisDVvVMMalariaEpilepsy口糖尿病Diabetes心曦病HeartDisease口匍藏病KidneyDisease口肝曦病LiverDisease口精神疾患Psychosis他Other()2.H、食物、勤物、他早一方135力、。Doyouhaveanyallergiestodrugs,foods,animalsandother?Yes具体的音已入Pleasespecify.(No3.琨在、何力、内病常用杀寸力、。Areyoutakingmedicatio

3、nnow?病名Disease(Yes服用蕖medication(NoPhysician1.身体检查PhysicalExamination身Height血压BloodPressureEyesight(R)cmmm/Hg体重Weightkgmm/Hg.(L)裸N艮withoutglasses(R)血液型RHBloodType(L)withglassesorcontactlensesAB色竟累常内有瓢colorblindness正常normalII常impaired2.X日1检查内日付已入寸己二( 6勺月以上前内检查瓢勃) 's chest (X-ray taken more than 6

4、months priorM力正常normalHearing低下impaired申言青者内胸部巨/、P、x,1检查内结果在言己入PleasedescribetheresultsofphysicalandX-rayexaminationsofapplicanttothecertificationisNOTvalid).肺Lung正常normalII常impaired心nHeart口正常口昊常normalimpairedDescribetheconditionofapplicant'slung.心霜因Electrocardiograph:正常normalII常impaired.检查Labor

5、atorytests检尿Urinalysis糖Glucose(),蛋白Protein(潜血Occultblood血液检查Bloodtest赤血球数WBCcount:x104/|il,白血球数WBCcountP.Pleasedescribeyourimpression.5.志K者内既往摩，t察?检查内结果力、判断,琨在内健康状况十分留学耐完5内占思力九兴寸力、？Inviewoftheapplicant'shistoryandtheabovefindings,doyouthinkhis/herhealthstatusisadequatetopursuestudyinJapan?YES/NO日付