CERTIFICATE OF HEALTH

CERTIFICATE OF HEALTH

NAME : Age : Sex :MF
Date of Birth :_________________________
Address :_________________________________________________
Ⅰ. PHYSICAL EXAMINTAION :
HEIGHT cm WEIGHT Kg
DISTANT VISION :
Uncorrected Rt. Corrected Rt.
Lt. Lt.
COLOR VISION :
HEARING ː Right. Normal( ) Abnormal( )
Left. Normal( ) Abnormal( )
BLOOD PRESSURE: Systolic mmhg Diastolic mmhg
LUNGS AND HEART :
ABDOMEN :
INFECTIOUS DISEASES :
OTHERS:
Ⅱ. NEUROPSYCHIATRIC EXAMINATION:
NEUROLOGIC Normal( ) Abnormal( )
Psychiatric Normal( ) Abnormal( )
Ⅲ.X-RAY EXAMINATION :
Film No () Date
Result :
Ⅳ. LABORATORY FINDINGS:
LAB.No.()
Urinalysis :
Stool Test :
Blood Hemoglobin :g/dl E.S.R MM/hr
Serology :S.T.S(Cardiolipin)
G.O.T:()
G.R.T:()
HBS-Ag :()
Anti-HBS :()
Skin Test : Tuberculin Positive:() Negative:()
Others :
Ⅴ. SUMMARY OF THE EXAMINING PHYSICIAN :

M.D
date :_____________________

○○○ HOSPITAL
○○-○○○○○-DONG ○○-KU ________. KOREA

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