작성일 2020.05.28. 버전 SCH 1.0 작성일 2020.05.28. 버전 SCH 1.

3. Physical Examination
Certificate of Health Blood Pressure : Systolic ________________ Diastolic _______________ mmHg
(Name) (Sex)
Vision : Right ______________ / 20 Left ______________ / 20 ColorVision _________________
□ M □ F Corrected : Right ____________ /20 Left __________ /20
(Photo)
(Passport Number) (Date of Birth) (DD/MM/YY) Clinical Evaluation:
3㎝×4㎝
Classification Normal Abnormal Classification Normal Abnormal
Skin Heart
Address
Head & Face Abdomen
Phone Eyes Rectum
Ears Genitalia
Mobile
Mouth & Throat Extremities
E-mail Nose & Sinuses Back & Spine
Neck Neurological
1. Laboratory Examination Chest & Lungs Mental health
(Please attach evidential documents which prove that the result of the following examinations is true and correct Other
; otherwise, It is not valid.)
If any symptoms below, please mark(if nothing found, please mark ‘NOTHING’)
Test Result Remarks □ Fever over 37.5°c □ Feeling heat □ Taking fever reducer □ Chill □ Fatigue □ Cough
HBsAg □ Negative □ Positive □ Runny nose □ Sputum □ Breathing problem □ Sore throat □ Muscle pain □ loose
Hepatitis B
anti-HBs □ Negative □ Positive your taste or smell of sense □ Digestive symptoms(nausea, abdominal pain, diarrhea)

Treponemal test □ Negative □ Positive Please check test modality □ etc... ( ) or □ nothing
…………………………………………… 4. Are there any suspected findings of infectious diseases or endemic diseases?
Syphilis test
Non-Treponemal test □ Negative □ Positive (ex. FTA-ABS, TPPA, TP-EIA, (Covid-19, Mers, Ebola virus, Zika virus, etc.)
CIA) □ Yes (If ‘Yes’, please provide details.) ___________________________________________________________
1. HIV-1/2 Immunoassay
□ No
□ Negative □ Positive Please explain test results if
positive : 5. Does he/she have any medical conditions that will require frequent or long periods of
2. HIV-1/HIV-2 antibody differentiation absence, or would otherwise affect his/her ability to carry out role given to him/her in
HIV immunoassay if no.1 positive participating in intensive training course away from home for 17 months?
□ Negative □ Positive □ Yes (If ‘Yes’, please provide details. ex. Diabetes, Hypertentions etc., )
3. Other method □ Negative □ Positive ___________________________________________________________________________________________________________
□ No
Blood hemoglobin …………….……… g/dl or ………………… mmol/L
6. Are there anything in the person’s medical history that would make him/her unfit to
Alanine transaminase participate in the training course?
……………………... IU/L or …………………… ukat/L
(ALT) □ Yes (If ‘Yes’, please provide details.) ___________________________________________________________
Fasting Plasma Glucose ……………........... mg/dl or …………………… mmol/L □ No
I certify that I answered all questions truthfully and completely to the best of my knowledge.
Protein □ Negative □ Positive Please if positive :
Date of Examination (DD/MM/YY)
Urine(Dipstick) Glucose □ Negative □ Positive Medical Institution Stamp
Blood □ Negative □ Positive Name of Medical Institution

Pregnancy test Name of Physician

Urine HCG □ Negative □ Positive
(Women Only)
Physician Signature
Tuberculosis PPD □ Negative □ Positive Please explain if other tests (Stamp)
were taken additionally : (E-mail)

Contact Information of
Chest X-ray(PA) Chest X-ray □ Negative □ Positive Physician (Phone Number)