CERTIFICATE OF HEALTH
CERTIFICATE OF HEALTH
CERTIFICATE OF HEALTH
NAME : Age : Sex :MF
Date of Birth :_________________________
Address :_________________________________________________
Ⅰ. PHYSICAL EXAMINTAION :
HEIGHT cm WEIGHT Kg
DISTANT VISION :
Uncorrected Rt. Corrected Rt.
Lt. Lt.
COLOR VISION :
HEARING ː Right. Normal( ) Abnormal( )
Left. Normal( ) Abnormal( )
BLOOD PRESSURE: Systolic mmhg Diastolic mmhg
LUNGS AND HEART :
ABDOMEN :
INFECTIOUS DISEASES :
OTHERS:
Ⅱ. NEUROPSYCHIATRIC EXAMINATION:
NEUROLOGIC Normal( ) Abnormal( )
Psychiatric Normal( ) Abnormal( )
Ⅲ.X-RAY EXAMINATION :
Film No () Date
Result :
Ⅳ. LABORATORY FINDINGS:
LAB.No.()
Urinalysis :
Stool Test :
Blood Hemoglobin :g/dl E.S.R MM/hr
Serology :S.T.S(Cardiolipin)
G.O.T:()
G.R.T:()
HBS-Ag :()
Anti-HBS :()
Skin Test : Tuberculin Positive:() Negative:()
Others :
Ⅴ. SUMMARY OF THE EXAMINING PHYSICIAN :
M.D
date :_____________________
○○○ HOSPITAL
○○-○○○○○-DONG ○○-KU ________. KOREA
NAME : Age : Sex :MF
Date of Birth :_________________________
Address :_________________________________________________
Ⅰ. PHYSICAL EXAMINTAION :
HEIGHT cm WEIGHT Kg
DISTANT VISION :
Uncorrected Rt. Corrected Rt.
Lt. Lt.
COLOR VISION :
HEARING ː Right. Normal( ) Abnormal( )
Left. Normal( ) Abnormal( )
BLOOD PRESSURE: Systolic mmhg Diastolic mmhg
LUNGS AND HEART :
ABDOMEN :
INFECTIOUS DISEASES :
OTHERS:
Ⅱ. NEUROPSYCHIATRIC EXAMINATION:
NEUROLOGIC Normal( ) Abnormal( )
Psychiatric Normal( ) Abnormal( )
Ⅲ.X-RAY EXAMINATION :
Film No () Date
Result :
Ⅳ. LABORATORY FINDINGS:
LAB.No.()
Urinalysis :
Stool Test :
Blood Hemoglobin :g/dl E.S.R MM/hr
Serology :S.T.S(Cardiolipin)
G.O.T:()
G.R.T:()
HBS-Ag :()
Anti-HBS :()
Skin Test : Tuberculin Positive:() Negative:()
Others :
Ⅴ. SUMMARY OF THE EXAMINING PHYSICIAN :
M.D
date :_____________________
○○○ HOSPITAL
○○-○○○○○-DONG ○○-KU ________. KOREA
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NATIONAL HEALTH INSURANCE CORPORATION REPUBLIC OF KOREA
NATIONAL HEALTH INSURANCE CORPORATION REPUBLIC OF KOREA 168-9, Yeumri-dong, Mapo-gu, Seoul, KOREA.(121-749)/Tel( )- /Fax( )- Manager : Assistant Manager : Deputy : CERTIFICATE OF THE INSURED .. -
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