Certificate Of Health Form

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Form D
Certificate of Health (Form D)
Name:
Family Name
Given Name
Sex and Date of Birth:
Sex
Date of Birth
Height:
cm Weight:
kg
Blood Pressure:
/
mmHg
Vision: Naked (R)
(L)
Corrected (R)
(L)
Color Distinction:
Hearing:
Medical History:
a. Tuberculosis
b. Kidney problem
c. Neural problem
d. Heart Problem
e. External injury
f. Liver problem
g. Polio
h. Epilepsy
i. Respiratory problem
j. Problem of the limbs
k. Others
If you have marked any of the above, please describe it in detail below.
Present state of health: please describe it in detail if any illness or abnormality found.
Please explain in detail the state of the lungs. Please enter the date and the result of X-ray
photography.
1

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