電 気 通 信 大 学
Certificate of Health T h e U n i v e r s i t y o f
E l e c t r o - C o m m u n i c at i o n s
for Overseas Applicant to UEC
UEC : The University of Electro-Communications, Japan Form H
= Note: This document is to complete by a registered physician only. =
I. Applicant Information (Please check with passport, Student ID and other certified document.)
Last Name in English : Sex : Male / Female
First Name(s) in English : Date of Birth : (D) /(M) /(Y)
Country of Birth : Nationality :
II. Physical Examinations
Height: cm Weight: kg Pulse Rate: /min. Regular / Irregular
(circle appropriate)
Blood Pressure: (High) / mm/Hg
Visual acuity without glasses : (R) /(L)
with glasses : (R) /(L) (if applicable)
Colour Blindness: Normal / Impaired Note:
(circle appropriate)
Hearing : Normal / Impaired Note:
(circle appropriate)
Speech : Normal / Impaired Note:
(circle appropriate)
Other physical : Normal / Impaired Note:
function : (circle appropriate)
Chest X-Ray : Normal / Impaired Filmed Date: (D) /(M) /(Y)
(circle appropriate) (X-Ray must be less than 3 months old from date of entry to this form.)
Please describe the condition of applicant’s lung briefly:
III. Laboratory tests
Please indicate with + or – in each blacket. If positive, write the detail of test data.
Urinalysis : ( ) Glucose ( ) Protein ( ) Occult blood
Blood Test: WBC count: /cm m Hemoglobin: gm/dl GOT:
©The University of Electro-Communications
1999ISC-HC (Ref.No.ISC-HC991124F.UEC)
IV. Past Histroy
Please indicate with + or – in each blacket. If positive but recovered, write the date of recovery.
+/- +/-
( ) Tuberculosis.....(Date: ) ( ) Renal Disease......................... (Date: )
( ) Epilepsy.......... (Date: ) ( ) Drug Allergy............................ (Date: )
( ) Diabetes.......... (Date: ) ( ) Other communicable disease... (Date: )
( ) Malaria............ (Date: ) ( ) Psychosis............................... (Date: )
( ) HIV................. (Date: ) ( ) Hepatitis. ................................ (Date: )
( ) Functional Disorder in extremities.....(Date: )
Write the detail if positive,
V. Physical/Medical/Psychiatric/Supplemental Note:
(A) Is this applicant on any kind of Medication?
No / Yes => Write the Name of Medicine: Doze
=> What is this medication for?
=> How often the applicant has to take?
(B) Does this applicant have special diet? No / Yes => Write the detail:
(C) Supplemental Note and Suggestion for applicant’s general health:
VI. Summary of Applicant’s Health:
(A) Do you think that this applicant health status is adequate to purse Yes / No
university study in Japan?
(B) Do you think that this applicant health status is adequate to purse Yes / No
industrial training and work in Japan?
(C) If No for either of questions above, please write the detail:
VI. Declaration of Examining Physician
I declare that information provided by me in this certificate is solemnly true and correct to my best
knowledge.
Physician’s Full Names in Print Letter:
Medical Office / Institute :
Contact Address :
Contact Phone No. :
Physician’s Signature: Date: / /
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