ACC-05NameinfullDateofBirthMedicalItemsHeightWeightCheckPositivedoubtfulNegativeEyesightLeft()Right()LatestTuberculinReaction:DateofExaminationormalncompleteColorBlindx-RayPhysicalImpedimentItemsIndicatewith(0)foryesand(x)fornoSightLeftRightHearingLeftRightJointNormalAbnormal(No.ofPhotograph)SpeakingPhysicalExerciseFindingsRemarksMedicalHistoryandAgeofDiseaseMentaldisorderTuberculosisAgeInfantileAgeAgeOthersBronchialAsthmaAgeEpilepsyAgeCardiacDiseaseAgeNervousDiseaseAgeAnydiseaseneedtobecheckedafterentranceStomachDiseaseAgeMentalDiseaseAgeRheumatismAgeOthersAgeBloodtype,:Inmyopinionthegeneralstateoftheapplicant'shealthisExcellentGoodFairPoorIherebycertifytheabovestatementsaretrue.DateofExaminationYearMonthDayInstitutionandAddressFullNameandSignatureofDoctorStamp