CERTIFICATE OF HEALTH (to be completed by the examining physician)

Please fill out (PRINT/TYPE) in Japanese or English. Name: , Male Female Date of Birth:

Family name,

First name

Middle name

Physical Examination (1) Height (2) Blood pressure cm Weight mm/Hg kg mm/Hg Blood Type A B O RH Pulse Regular Irregular

(3) Eyesight: (R) (L) Without glasses (4) Hearing: Normal Impaired

(R) (L) With glasses or contact lenses Speech: Normal Impaired

Normal Color blindness Impaired

) Please describe the results of physical and X-ray examinations of the applicant's chest X-rays (X-rays taken more than six months prior to the certification are NOT valid). Normal Cardiomegaly: Impaired Date Film No. Electrocardiograph : Normal Impaired Describe the condition of applicant's lungs. Lungs: Disease currently being treated Yes (Disease No ) Normal Impaired

Past history : Please indicate with or and fill in the date of recovery (If the applicant has not contracted any of the disease, please chech None.) Tuberculosis......( . . ) Malaria.......( . . ) Other communicable disease......( Epilepsy......( . . ) Kidney disease.....( . . ) Heart disease......( . . ) Diabetes......( . . ) Drug allergy......( . . ) Psychosis.....( . . ) Functional disorder in extremities......( . . ) None..... Laboratory tests Urinalysis: glucose ( ESR: Hemoglobin: ), protein ( ), occult blood ( /cmm ) . . )

mm/Hr, WBC count: gm/dl, GPT:

anemia

Please give your impression of the applicants health. (If you do not have a particular opinion, please write as such.)

In view of the applicant's history and the above findings, is it your observation that his/her health status is adequate to pursue studies in Japan?

Yes
Date:

No
Signature:

Physician's Name in Print : Office/Institution: Address: