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(Self Medical Assessment) : (Form 6)

This document is a self-medical assessment form for applicants to a Korean government scholarship program. It requests information about the applicant's medical history, including any visits to physicians, serious illnesses, hospitalizations, mental health issues, disabilities, allergies, medications, or diets. The form notes that applicants are not required to get a medical exam before the second selection round but will need comprehensive exams after being selected and again upon arriving in Korea. It states that if exam results show an applicant is unfit for study and living abroad, they may be disqualified from the program.

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756 views1 page

(Self Medical Assessment) : (Form 6)

This document is a self-medical assessment form for applicants to a Korean government scholarship program. It requests information about the applicant's medical history, including any visits to physicians, serious illnesses, hospitalizations, mental health issues, disabilities, allergies, medications, or diets. The form notes that applicants are not required to get a medical exam before the second selection round but will need comprehensive exams after being selected and again upon arriving in Korea. It states that if exam results show an applicant is unfit for study and living abroad, they may be disqualified from the program.

Uploaded by

ahfaj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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[Form 6]

(Self Medical Assessment)


Please provide accurate information for the following questions.
Note: Applicants are not required to undergo an authorized medical exam before passing the 2nd
round of selection; however, all candidates must take a comprehensive medical exam after the 2nd
round of selection (see FORM 7); all grantees must take another comprehensive medical check-up
(including HIV, TBPE drug test) after coming into Korea in accordance with the requirements of the
Korea Immigration Service and the KGSP. If the results show that any grantee is unfit to study and live
overseas, he/she may be disqualified.

QUESTION YES NO EXPLAIN


When and for what reason did you last consult a At 12th April 2016 for complemented the
physician? (Please explain) regulation of STANs admission.
Have you had any serious ailment, injuries or
diseases (high blood pressure, diabetes,

tuberculosis, any type of Hepatitis, HIV, etc) in the
last five years? (If yes, please explain)
Have you been hospitalized in the last two years?

(If yes, please explain)
Have you ever been treated by a doctor for any
mental, emotional, or anxiety disorder?

(If yes, please explain and attach a report from your
doctor)
Have you ever been addicted to any substance?

(If yes, please explain)
Do you have any allergies? (If yes, please list them)
Do you have any visual or hearing impairment?
Do you have any physical disabilities?
Do you have any cognitive/mental disabilities?
Are you taking any prescribed medication?

(If yes, please explain)
Are you on a special diet?

(If yes, please explain in detail)
Have you ever suffered from depression?

(If yes, please explain)

THE ANSWERS I HAVE GIVEN ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. IF MY
ANSWERS CONTAIN ANY KIND OF FALSEHOOD, I WILL TAKE ANY LEGAL RESPONSIBILITY.

Date(yyyy/mm/dd): 2016 . 09 . 24

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

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