Health Certificate

【#文档大全网# 导语】以下是®文档大全网的小编为您整理的《Health Certificate》，欢迎阅读！

HEALTH CERTIFICATE

健康診断書

Full Name: Date of Birth:

(氏名) (生年月日)Year / Month / Day

3

Please answer the questions below by checking the appropriate box, before submitting to a physician for your physical examination. (健康診断を医師に申込む前に下記の設問に関しいずれかをチェックしてください。)



1. What diseases, disorders or injuries have you had in the past five years? (過去５年間にかかった病気あるいは

怪我の名を書いてください。)



2. Do you have any allergies to foods, plants or animals? Yes / No 3. Have you ever had an adverse reaction to medication? Yes / No 4. Are you taking medication now? (現在、何か薬を飲んでいますか。) Yes / No



(薬に対してアレルギーはありますか。) (食物、動植物にアレルギーはありますか。)

To the physician (医師の方へ):

Please review the applicant’s medical history and complete the information below, giving details concerning any positive indications. If there are any abnormalities in the following systems, circle the appropriate answer and explain in detail. (患者の病・傷害歴をお読みになってから診断、ご記入ください。もし何か徴候

がみられれば詳しくお書きください。下記の場所に異常がありますか。＋か－いずれかを○で囲んでください。)

1. 2. 3. 4. 5.

Head/Ears/Nose/Throat (頭/耳/鼻/喉) ＋／－ 6.Musculoskeletal (筋/骨) ＋／－ Respiratory (呼吸器) ＋／－ 7.Metabolic/Endocrine (代謝/分泌) ＋／－ Cardiovascular (心臓/血管) ＋／－ 8.Neuropsychiatric (神経精神) ＋／－ Eyes (目) ＋／－ 9.Skin(皮膚) ＋／－ Genitourinary(泌尿生殖器) ＋／－

Physician’s Comments (医師の所見):

After reviewing the applicant’s medical history and physical condition，I believe him/her to be in good physical and mental health, free of any chronic conditions, disorders or contagious diseases, and capable physically and mentally of completing a one to two semester term of study in KyotoUniversity. (患者の病歴と

健康状態を診た結果、私は上記の者が、肉体的にも精神的にも健康で、持病、伝染病、身体の不調無く、京都大学で1, 2学期間勉強を続けるのに支障はないと確信します。)



Physician’s signature (医師の署名): Date(日付): Year / Month / Day

Physician’s name(医師の名前): Address (住所): tel/fax/e-mail:

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