CERTIFICATE OF HEALTH

NAME :                                 Age :               Sex :  M · F

Date of Birth :

Address :

Ⅰ. PHYSICAL EXAMINTAION :

HEIGHT                   cm               WEIGHT                 Kg

DISTANT VISION :

Uncorrected Rt.                              Corrected Rt.

Lt.                                        Lt.

COLOR VISION :

HEARING ∑ 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 :

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○○-○○ ○○-DONG ○○-○○-KU SEOUL KOREA