SAMPLE MEDICAL CERTIFICATE Paperclip your MDs Business Card here

*
Doctor's/Physician's/Clinic's stamp here

I! ii ��1!1!t:·��� B ttt.El�Jl /DateofExami nation

V�t-tttt­ Health Certificate for Residence Application YYYY/MM/DD
Hospital's Logo CY.r;t,t�Jf}' !tl!.H:' '4!:1!' �JO
(Hospital's Name, Address, Tel, Fax) / /

£ * 1t ,lat / Basic Data

H. .,t
First, Middle, and Last Name
•li.>N : Check
□
one with an X
,J / M □ -k I F
Name Sex Please use the sex that is listed on your passport
�/Kl_�� A passport-style photo
Your ID/License number Your Passport number
Passport No.
�- J:l / Photo
ill !!. 1f- J3 a YYYY/MM/DD
Im ,ff
: / / USA , Canadian, and/or Other
Date of Birth Nationality
Jf#�il!:� Your phone number
Your current age
Phone No.

ft � '.£: .fQ- � / Laboratory Examinations

REQUIRED A. �� X 1t.Aip,�#i�1t I Chest X-ray for Tuberculosis :

X 1t.-ft-JJt /Findings: __ _ _ _ _ ___________
*'1 � I Result :
D %� / Passed D �1i;J.!rp,�Ht I TB suspect D �,'i,,tt.ittilllr /Pending D :;;i;:1;--;t� /Failed
r
D !j1 -!(f � 12 I;,. i:;._ $l i: ftMt I Not required for pregnant women or children under 12 years of age
NOT REQUIRED B. �pq !f !!.A.l-1t.�1t I Stool Examination for Parasites:
D �•ti • tt_,t I Positive, Species _ _ _____ D �•ti I Negative
D Jt,it. � :;;i;: -'f ��;1!.z.JW; pq !f !iii I Other parasites that do not require treatment _______
D *� Jlft�.;..-Z.@ 'fi../!t I& ::If 5tMt INot required for applicants from countries/areas listed in Appendix 3

REQUIRED C. #j.j.Jrz.5t-�i!i I Serological Tests for Syphilis :

(unless 14 ;J:tMt /Tests :
a. □ RPR □ VDRL
or younger)

D �•ti I Positive , rt1ft /Titers ____ D �•ti INegative , rt11t /Titers ____
b. 0 TPHA O TPPA O FTA-abs O TPLA O EIA O CIA
D �•ti I Positive , rt1ft /Titers ____ D �•ti INegative , �i1ft /Titers ____
c. D other _ ____ D �·ti I Positive , rt1ft /Titers ____
D �•ti /Negative, rt1J /Titers ____
*'1 � I Result : D %� /Passed D :;;i;:1;---tt /Failed
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D 15 I;,. l-:.{. 5l i: }t,$- /Not required for children under 15 years of age
REQUIRED D. 4:1}.&-1.t Im 4:1}.z.;bttt�•li.�1t:ffi.% �fU4°-ti�*eA I Proof of Positive Measles and Rubella
Antibody or Measles and Rubella Vaccination Certificates :
a. ;}itff.;J:t1t / Antibody Tests
/i,�;}itff. I Measles Antibody D �•ti I Positive D �•ti INegative D 5f-.4i� IEquivocal
tt@/i,�;}it:tt / Rubella Antibody D �•ti / Positive D �•ti /Negative D 5f-.�� /Equivocal
b. ffi F4°.:/ittti B.Jl /Vaccination Certificates (ti BA l.t @.¾.:/4tt BIA , .:fittF1c.falT &.?i 11i .:/�� ; .:fitt BIA
� ill @ B IA .l.t .f.. j,' M 1% � � / The certificate should include the date of vaccination, the name of
administering hospital or clinic and the batch no. of vaccine; the date of vaccination should be at least two
weeks prior to traveling overseas.)
D /i,�fyjF;q,titt_tiBA /Measles Vaccination Certificate
D 1.l@tfif,�fJU;q.:fitttiBA /Rubella Vaccination Certificate
c. D ;/if .:fitt � .� ' t," :;;i;: � 1i: fJi �;q.:fitt I Having contraindications, not suitable for vaccination
 5l !i. � � � I Examinations for Hansen's Disease
NOT REQUIRED �A' Jt.Jtill.t:iM* I Skin Examination
D _iE # /Normal
D � # /Abnormal : 0 ��il1..wi /Not related to Hansen's disease:
0 tt1Wl1..wi3�i!-3Vi'ft� I Hansen's disease suspect who needs further
examinations
a. wi J!. -!:JJ J:l / Skin Biopsy :
b. Jt/W:tiJ:l /Skin Smear: 0 1%--t.i /Positive 0 ft•ti I Negative
c. Jt/twi;k±.½1#-.@df:fl���'f!&.JltA. I Skin lesions combined with sensory
loss or enlargement of peripheral nerves: 0 � /Yes 0 #.. /No
*'15t I Result:
D ½� /Passed D 3�i!-ffeii� /Needs further examinations □
�½� I Failed
D * gi F!H.,-f; im :.t.. � */ !tl!. � :ff ft� / Not required for applicants from countries/areas listed in Appendix 4

1���� fa.�-�t* I The final result of health examination :

D ½ft / Passed D �JO!-ffe�� /Need further examinations D �½ft / Failed
Your Doctor must check one (hopefully "Passed")

� -f-1-ift-CifiJi,:f: I Signature of Chief Medical Technologist: _________ _

� -k.V-Cifift:f: I Signature of Chief Physician: __________ Only your Doctor's signature is required

Your Doctor's signature must be witnessed by a Notary Public

1-P?t.� -fA.*:f: I Signature of Superintendent: ______ _ _ _

El IJJ /Date: / / .
YYYY/MM/DD
11tt I Note : **� ;..100 }3 pq 1f � 0
/ The certificate is valid for three months.

The Notary Public can stamp this page or attach a notarization page to this form

Please be sure to read all the folowing information pages