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資料の原本内容
MEDICAL CERTIFICATE
ID:
DATE OF EXAMINATION :
HEIGHT
NAME:
/
/
cm
WEIGHT
DATE OF BIRTH :
kg
/
STANDARD Wt .
kg
SEX:
/
%OBESITY
%
RESPIRATORY ＆ CARDIOVASCULAR SYSTEM:
EKG:
B.P. :
/
mmHg
.
GASTROINTESTINAL TRACT SYSTEM:
FECES
BLOOD:
PARASITES:
BLOOD CHEMISTRY:
RBC
x10^4/mm3
Hb
g/dl
Ht
%
GOT
U
GPT
U
γ-GTP
Al-P
g/dl
LDH
U
T.Chol
mg/dl
UA
g/dl
FBS
mg/dl
T.Bil
mg/d
TP
g/dl
A/G
WBC
x10^3/mm3
ZTT
U
TG
mg/dl
SERO-IMMUNOLOGICAL TESTS:
URINALYSIS:
HAAb
HBsAg
ESR
mm/hr
PROTEIN
RBC
HBsAb
SUGAR
/ HPF
WBC
HCVAb
HIV
CRP
mg/dl
BLOOD
/ HPF
CASTS
BACTERIA
X-RAY:
CHEST
ABDOMEN
OTHER EXAMINATION:
DIAGNOSIS:
1.
2.
3.
REMARKS:
MEDICINE PRESCRIBED:
Physician’s Signature:
/ HPF
