2013 global korea scholarship korean Government Scholarship Program for International Students for an Undergraduate Degree icon

2013 global korea scholarship korean Government Scholarship Program for International Students for an Undergraduate Degree


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[Form 7]

의사 발급 건강 진단서

(Certificate of Health)


This certificate will be highly appreciated in the process of selection of Korean Government Scholarship recipients and the admissions to a Korean university. Please attach evidential documents which prove that the result of the following examinations is true and correct; otherwise, it is not valid.


1. Personal Information                                                      

Full Name:

Sex:

Date of Birth:

Nationality:


^ 2. Physical Examination                                                      

   Blood Pressure: Systolic              Diastolic             mmHg

Vision: Right 20/                Left 20/               Color Vision                   

   Corrected: Right             /15  Left             /15

   Dental Evaluation: Good (    )  Fair (    )  Poor (    ) Needs Attention (     )

  Clinical Evaluation:

Classification

Normal

Abnormal

Classification

Normal

Abnormal

Skin

 

 

Heart

 

 

Head & Face

 

 

Abdomen

 

 

Eyes

 

 

Rectum

 

 

Ears

 

 

Genitalia

 

 

Mouth & Throat

 

 

Extremities

 

 

Nose & Sinuses

 

 

Back & Spine

 

 

Neck

 

 

Neurological

 

 

Chest & Lungs

 

 

Mental

 

 

 

 

 

Other

 

 

If Abnormal:


^ 3. Chest X‐ray Examination

uni000001dc0451    Date taken:

uni000001dc0453    Findings:


^ 4. Laboratory Examination

   Hemoglobin:                Gm/dl

Urine: S.G.                  Sugar               Micro                

uni000001dc0455Hepatitis B:

uni000001dc0457Stool for Parasite Oval:

uni000001dc0459Serological Test for Syphilis:                                                   

Other:  

                                                         In my opinion his/her health condition is;

Excellent (  )  Good (  )   Fair (  )   Poor (  )


This is to certify that the above named applicant has gone through a general medical examination and the findings indicated here are true and correct to the best of my knowledge.


Date

 

 

Hospital or Institute

M.D

 

 

Signature



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