健康诊断证明书

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