ࡱ> TVS5@@;bjbj22YXX 8$%fff$$$$$$$$'R)`%QSfSS% p%C$C$C$SFl$3$S$C$C$U$r,U$ .b!U$$%0%U$P*" P*U$P*m$xf"!$fff%%$ #|eP^:ef CERTIFICATE OF HEALTH (to be completed by the examining physician) e,gSo0񂞊k000fwk0 Y00S0h00 Please fill out (PRINT/TYPE) in Japanese or English. l T 0000000000000000 000000000000000%7u Male 00 ut^ge 0 0 00t^b Name: 00000000000000, 000 0000000000 0 %sY Female Date of Birth: 0 00 0Age: 0000 Family name, 000000000First name Middle name SOig 00Physical Examination 0(1) 0w000000000 SO0͑ 000 Height00000 cm 0 Weight00000 kg  0(2) @0'W0000000000000 00 @mW 000000000000b %te regular 000 Blood pressure 000000 mm/Hg^ 0000 mm/Hg 00Blood type 00 00000000Pulse0 % Nte irregular 0(3) 0R 000 Eyesight: (R) 0(L)000000 (R) 00 (L)0000 rpu8^n0 g!q00 %ck8^ normal 000 00000 @DFXZ^`fhz|    & * . 0 P R t v 䭠不uhh{M@^Jo(hh6OJQJo(hh1^JhhwE^Jo(hh1@PJ^Jhh1PJ^Jhh1OJQJo( hh1@CJPJ^JaJhh1CJPJ^JaJhh1@#hh1@CJOJQJaJo(. ( * b  > L   $ gd{M$d$a$$da$;;>;v ~   ( * . 0 < > @ D H V X ` b f n p | ~ ܴܨܜܨʋ jhh1UmHnHuhh{M@^Jo(hhZ8/OJQJo(hh{MOJQJo(hh6^Jo(hh1@hh1^Jhh1OJQJo(hh1@PJ^Jhh1PJ^J6     2 6 < > D F R \ ^ b h j n z {odhh{MPJ^Jhh{MOJQJo( jhh{MUmHnHuhh{M@o($jhh{M@UmHnHu+jhh}OJQJUmHnHo(uhh1^Jo(hh1@o(hh1@PJ^Jhh1OJQJo(hh1@hh1PJ^J% * 2 6 < J L N T V ` b r v 󶭑zzs h^D^Jo(hh{M^Jo(h^D@OJQJ^Jo(7jhh}@CJOJQJUaJmHnHo(uhh{M@hh{MPJ^Jh^D@^Jo(hh{M@^Jo( hh{M@CJ PJ^JaJ hh{MOJQJo(hh{M@PJ^J*      " $ * , > @ F X Z ` j l n t ~ źwk_khhc(OJQJo(hhc(@^Jo(hh1@hh1@PJ^Jhh1PJ^Jhh1OJQJo(hh}OJQJo(hh{M^Jo(hh{MPJ^Jhh{M@PJ^Jhh{MOJQJo(h^D@^Jo(hh{M@^Jo(hh}@^Jo(  "(*.028:HJNP^`lnz|hh1CJOJQJaJo(hhc(@^Jo(hhAd^Jo( jhh1UmHnHuhh1@hh1PJ^Jhh1OJQJo(hh1@PJ^J#hh1@CJOJQJaJo(2 (8:@BRThjvx~&(268RTZ\bdrt޴Ӆhh1^Jo(hhc(@^Jo(hhAd@^Jo(hh1@PJ^Jhhc(@^Jo(hhAd^Jo(hh1@hh1PJ^Jhh1@PJ^Jhh1OJQJo(hh1^J4(tv|bxL0111112n384444h5j55 @WD`@gdc(tvxz|48>@P`b||phhc(@^Jo(hhAd^Jo( hh1@CJPJ^JaJhh1PJ^Jhh1@PJ^J hh1@CJ PJ^JaJ hh1OJQJo(hh1@hhB^J,jhhB@PJU^JmHnHuhhB^Jo(*bd  hnv$,28\^`fhtvxz068HJLR|~hh@^Jo( jhh1UmHnHuhh1PJ^Jhh1@hh1OJQJo(hhc(@^Jo(hh1@PJ^J jhhc(UmHnHu<0000$0(0*0X0000000001111111,1.10121>1@1P1R1Z1\1^1`1d1f1h1j1p1r1z1|111111111Ÿ⸕ŸŸhh@^Jo(hTz@^Jo(hhAd@^Jo(Uhh1@PJ^Jhh1OJQJo( jhhTzUmHnHuhh1@hhAd^Jo(hh1PJ^J: %Yes (Conditions/particulars: ) Under medical treatment at present %No e_u 00Past history : Please indicate with or and fill in the date of recovery 00Tuberculosis......%( . . ) Malaria.......%( . . ) Other communicable disease......%( . . ) 00Epilepsy......%( . . ) Kidney disease.....%( . . ) Heart disease......%( . . ) 00Diabetes......%( . . ) Drug allergy......%( . . ) Psychosis.....%( . . ) 00Functional disorder in extremities......%( . . ) i0g0Laboratory tests 00i ?\0Urinalysis: glucose ( ), protein ( ), occult blood ( ) 00dl ESR:0000mm/Hr, WBC count:0000/cmm @ %  anemia 00Hemoglobin:0000gm/dl, GPT:  _Xn0e_tk :[0ign0P}gK00$ReW0f0 s(Wn0eP^n0rlo0EQRk0Yuf[k0H0F000n0h0`00~0Y0K0 YesSo0Nok000000W0f0O0`0U0D00 0In 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 ? 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