This document is a certificate of medical examination completed by a examining physician. It contains the name, date of birth, address and physical examination results of the applicant, including height, weight, blood pressure, and pulse. It also includes the results of x-ray examinations of the lungs and heart, vaccination records, and laboratory test findings. The physician indicates whether the applicant has any current or past medical issues and provides an assessment of whether the applicant's health is adequate to study in Korea.

1. Certificate of Medical Examination
(to be completed by the examining physician)
Certificate No.:
Name:
Date of Birth: Age: Sex: □ Male □ Female
Address:
1. Physical Examinations
Height: cm Weight: Kg
Blood Pressure: / mmHg Blood Type: Pulse: /min
□ regular □ irregular
2. X-Ray Examination (X-ray taken more than 6 months prior to the certificate is NOT
valid)
2-1. Lung Film No. ( ) Date:
Result: □Normal □Impaired ( )
2-2. Heart: □Normal □Impaired (Electrocardiograph: □Normal □Impaired)
3. Certificate of Vaccination (Routine):
4. Laboratory Findings
CBC: U/A:
OT/PT: BUN/cr:
VDRL:
HBS-Ag: Anti-HBS:
Anti-Retro Virus (AIDS)
5. Disease Treated at Present : □Yes ( ) □No
6. Past Medical History: □Yes ( ) □No
6. In the general state of the applicant's health good enough for his/her to pursue the course of
study contemplated in Korea?
□ Excellent □ With prudence, probably no serious problem □ Adequate □ Doubtful
Date: Signature:
Physician's Name in Print:
Office/Institution:
Address: