健康診断書 - healthcarecenter.osaka-u.ac.jp.docVIP

CERTIFICATE OF HEALTH to be completed by the examining physician Please fill out PRINT/TYPE in English. Name: , Male　　?Female Date of Birth: / / M/D/Y Age: 1. Physical Examination 1 Height: cm Weight: kg 2 Blood pressure: ～ mm/Hg 　　Pulse:regular　irregular 3 Eyesight: Without glasses R L With glasses or contact lenses R L 4 Hearing: ?normal ?impaired Speech: ?normal ?impaired 5 Lungs: ?normal ?impaired Heart: ?normal ?impaired → Electrocardiograph: ?normal ?impaired 2. Chest X-ray examinations Record within 6 months Date Describe the condition of applicants lungs. 3. Urinalysis : glucose protein occult blood 4. Under medical treatment at present : ?No ?Yes → Conditions/particulars : Physical disability : ?No ?Yes → Conditions/particulars : 5. Past history : Please indicate with or －. Tuberculosis : Malaria : Other infectious disease : Epilepsy : Psychosis : Kidney disease : Heart disease : Lung disease : Gastrointestinal disease : Thyroid disease : Collagen disease : Diabetes mellitus : Drug allergy : Others : 6. Status of immunization Varicella : Indicate the date of varicella vaccine or a physician documented history of varicella or serologic evidence of immunity. History of Varicella : Yes No Date of diagnosis : / / Immunization : Date 1: / / Date 2: / / Antibody Titer : Date: / / Result: copy attached Rubella : Indicate the date of rubella vaccine or a physician documented history of Rubella or serologic evidence of immunity. History of Rubella : Yes No Date : / / Immunization : Date: / / Antibody Titer : Date: / / Result: copy attached Measles : Indicate the date of measles vaccine or a physician documented history of disease or serologic evidence of immunity. History of Measles : Yes No Date : / / Immunization : Date 1: / / Date 2: / / Antibody Titer : Date: / / Result: copy attached Mumps : Indicate the date of measles vaccine or a physician documented history of disease or serologic evidence of immunity. History of