□Glucose□□□□□□□□□□)□□□□□□□□□□□□ yyyy Time(s)IU/□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ □□□□□□□□□□□□□□□lease be sure to check either "YES" or"NO"□ If you do not tick "YES", the Embassy will NOT acceptthe application□Middle name□□□□□□□□□□□□□□□□□□□□□□□□□mm ddTime(s)gm/dl□□□□Yes yyyy □□□□□□□□□□□□□□□If already vaccinated, indicate thenumber of vaccinationsUrinalysis(2) □□□□□nemia test(3) □□□□□LFT□□□With glasses orcontact lensesComment for the chest X-rayCERTIFICATE OF HEALTH (for □□□□) (to be completed by the examining physician)Please fill out (□□□□□□□□□□) in Japanese or English.□□□nemia□□Occult blood□□Protein□□□TP□□Name□□Gender□□□□□□□□□□□hysical examination(1)□□□eight(3)□□Blood pressure(5)□□Pulse(6) □□Eyesight Value□□□□□□□□□□□□□□□□□□□□□□□□hysical and X-ray examinations of the chest□(within six months)□□□□□Date of X-ray□□□□□□□□□□□□Disease currently being treated □□□□□□□□ast illness/disorder□□ □□□□□□□Vaccination History□□□□□□Laboratory tests(1) □□□□□ES□GPT(□LT)□□□□□□□□□□□□□□hysician's impression of the applicant□s health(1) □□Overall impression(2) □□□□□□□□□□□□□□□□□□□Is there a need for regular treatment and medication?(3) □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□In view of the applicant's history and the above findings, is ityour observation that his/her health status is adequate topursue studies in Japan?□□□□Physician's Signature□□□□□Office/Institution□□□□le□□Femalemm□g□□ □□□egular□ □□□Irregular/min□□Without glasses□□□□□□□□□□□□□□□□□mm (1) □□Lungs(2) □□□Cardiomegaly(3) □□□□□Electrocardiograph(4) □□□□□□□ □□□□ □□□□Yes ( □□□Name of diseas□□□□□Tuberculosis□□□□□□□laria□□□□□□□Other communicable disease□□□□□Epilepsy□□□□Kidney disease□□□□□□□rt disease□□□□Diabetes□□□□□□□ Drug allergy□□□□□Psychosis□□□□□□□Functional disorder in the extremitiesMM□ (Measles, Mumps. □□bella)□□ (Measles, □ubella)M (Measles)Mumps □ Negative□ Positive□□□□WBC countkg□□□□Date of Birth□□□□B□□□B□□O□ □□□□□rmal□ □□□Impaired□ □□□□□rmal□ □□□Impaired□ □□□□□rmal□ □□□Impaired□ □□□□□rmal□ □□□Impaired□ □□□□□rmal□ □□□Impaired□ □□□□□rmal□ □□□Impaired□□□□□□□ of below□epatitis BChicken poxMeningitisPolioDiphtheria Pertussis Tetanus combined□□□□□emoglobin□ □□□No□ □□□Yes□ □□□□No□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ If it's applicable, tick □ and fill inthe date of recovery/undertreatment.If NOT contracted any of them inthe past, tick “None of below”.□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□Given name□□□□□/cmmIU/□Surname□□□□ □/□□□□□□□□□□□/L □/□□□□□□□□□□□/LddMM□□ (Measles, Mumps. □ubella, Zoster)□□□□rIU/□ GOT□□□□)(2)□□cmWeight(4)□□□Blood type(7)□□□□□□□Color blindnessmm□g(8)□□□earing(9)□□Speech□□□□□□Film No.□ Negative□ Positive□□Date□□□□□□ress□□□□□□□□□ (4)□□□o to (4)□ (3)□□□o to (3)□ Negative□ Positive□ Negative□ Positive□ (1)□□□Fill in (1)
元のページ ../index.html#38