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ACC-05NameinfullDateofBirthMedicalItemsHeightWeightCheckPositivedoubtfulNegativeEyesightLeft()Right()LatestTuberculinReaction：DateofExaminationormalncompleteColorBlindx-RayPhysicalImpedimentItemsIndicatewith(0)foryesand(x)fornoSightLeftRightHearingLeftRightJointNormalAbnormal(No.ofPhotograph)SpeakingPhysicalExerciseFindingsRemarksMedicalHistoryandAgeofDiseaseMentaldisorderTuberculosisAgeInfantileAgeAgeOthersBronchialAsthmaAgeEpilepsyAgeCardiacDiseaseAgeNervousDiseaseAgeAnydiseaseneedtobecheckedafterentranceStomachDiseaseAgeMentalDiseaseAgeRheumatismAgeOthersAgeBloodtype，：Inmyopinionthegeneralstateoftheapplicant'shealthisExcellentGoodFairPoorIherebycertifytheabovestatementsaretrue.DateofExaminationYearMonthDayInstitutionandAddressFullNameandSignatureofDoctorStamp
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本文标题：健康诊断证明书
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