Medical Report Kanazawa Univ.

Use Only

Section A: to be completed by the student

Male Female
Furigana Sex


Name Home
Institution

Examinee
Birthdate
year month day Number

Section B: to be completed by the students physician who is not his/her parent or other relative

Examination Items Physicians Evaluation
Without glasses: Normal
R with glasses/contacts:
Eyesight Without glasses: If there is any abnormality, please explain it
L with glasses/contacts below.

Normal
R Abnormal (Descriptions: )
Hearing Normal
L Abnormal (Descriptions: )


X-ray Date year month day
Chest X-ray
1
Issues pertaining to school attendance:

Film No. None
(X-rays taken
in the past
1 year) Observations If you have any recommendations for this
students health care while at Kanazawa
Normal University, please explain.

If there is any abnormal condition, please explain.
Condition on the
other systems

I certify that, to the best of my knowledge, the information provided here is true, correct, and complete.

year month day Name of Physician

Name of Medical Institution

Address

Signature of Physician

Notes on Completing the Form

Please stipulate eyesight result as naked or corrected.

Please tick applicable boxes. In case there is any abnormality, please explain in details.
1
An X-ray photo taken during the past 1 year prior to submission should be examined.
+81-76-264-5255
Please contact the Health Service Center with any questions (PH: +81-76-264-5255).