Medical examination form中文.docxVIP

Medical examination formPart 1: To be completed by applicant Students Name: _____________________ E-mail Address: ___________________________Passport #: _________________________ Medical History: Please check all that apply and include dates _____ Heart Disease (including Rheumatic Fever) ___ / ___ / ____ _____ Gastrointestinal Disease (including ulcer) ___ / ___ / ____ _____ Liver Disease ___ / ___ / ____ _____ Kidney Disease ___ / ___ / ____ _____ Mental Disease (including depression) ___ / ___ / ____ _____ Neurological Disease (including epilepsy) ___ / ___ / ____ _____ Lung Disease肺 (including asthma) ___ / ___ / ____ _____ Diabetes ___ / ___ / ____ _____ Tuberculosis ___ / ___ / ____ _____ Anemia ___ / ___ / ____ _____ Hernia ___ / ___ / ____ _____ Hypertension ___ / ___ / ____ _____ Eating Disorder ___/___/_____心脏病(包括风湿热)___ / ___ __________胃肠道疾病(包括溃疡)___ / ___ __________肝病___ / ___ __________肾病___ / ___ __________精神疾病(包括抑郁症)___ / ___ __________神经系统疾病(包括癫痫)___ / ___ __________肺部疾病肺(包括哮喘)___ / ___ __________糖尿病___ / ___ __________肺结核___ / ___ __________贫血___ / ___ __________疝___ / ___ __________高血压___ / ___ __________进食障碍___ / ___ _____Other diseases not listed above (including dates): ______________________________________ _______________________________________________________________________________ Detail major operations and/or hospitalizations (including dates): __________________________ _______________________________________________________________________________ Detail all allergies and drug reactions: ________________________________________________ _______________________________________________________________________________ Applicants Statement: I hereby certify to the best of my knowledge that the above medical information is correct. I understand that any illness suffered prior to arriving in Israel that has not been described on this medical form may result in my return to my country of origin a