Medical Certificate - The Hebrew University of Jerusalem

The Hebrew University of Jerusalem
The Robert H. Smith Faculty of Agriculture, Food & Environment
International School of Agricultural Sciences
Medical Certificate 2016
First and middle name (as it appears on your Chinese
passport):
Family name (as it appears on your Chinese
passport):
Instructions:
Print out this form and have it completed by a medical officer of the Ministry of Health in your country of
residence or by a registered medical practitioner approved by such medical officer. It must be completed
only after a thorough clinical examination.
Applicant's country of residence:
Date of birth (dd/mm/yy):
Gender:
Length of acquaintance with applicant’s medical history and condition (please check one):
New patient (first visit)
Less than 1 year
1-3 years
3-8 years
More than 8 years
1. MEDICAL HISTORY
To the best of your knowledge, including your examination and lab results, has the applicant suffered in
the past from problems related to:
Date
Heart (cardiovascular)
Yes
No
Lung and respiratory system (TB, asthma, tumor, etc.)
Yes
No
Stomach, intestines, liver, kidney (nephritis, stones, etc.)
Yes
No
Nervous system (convulsions, stroke, mental illness, stress
related disorders, etc.)
Yes
No
Glandular system (such as goiter, diabetes, anemia)
Yes
No
Skin, muscles, bones, joints
Yes
No
Sensory organs (eyes, ears, etc.)
Yes
No
STD (sexually transmitted diseases)
Yes
No
HIV
Yes
No
Page 1 of 2
Noa Schwarzwald, Head of International Programs
International School for Agricultural Sciences, Robert H. Smith Faculty of Agriculture, Food & Environment, Herzl Street, POB 12, Rehovot, Israel
7610001
Email: [email protected]
Tel: 972-8-9489996 Fax: 972-8-9470171
The Hebrew University of Jerusalem
The Robert H. Smith Faculty of Agriculture, Food & Environment
International School of Agricultural Sciences
2. MEDICAL EXAMINATION
If the answer to a question is "yes," please give details in the field on the right or on a separate page.
3) Is there evidence of abnormality of:
Heart and cardiovascular system
Yes
No
Lung (emphysema, etc.)
Yes
No
Abdomen (liver, spleen, hernia or other)
Yes
No
Head and neck (vision, hearing, speech, thyroid, etc.)
Yes
No
Yes
No
Yes
No
Yes
No
HIV
Yes
No
Wounds or diseases requiring medical treatment
Yes
No
Yes
No
Yes
No
Yes
No
Nervous system (including hospitalization for mental illness
or treatment for stress-related disorders)
4) Does the patient currently have:
Infectious diseases (TB, trachoma, malaria, bilharzias,
leprosy, etc.)
STD
Chronic physical, mental or emotional states or problems
5) Does the patient require medication or have any dietary
restrictions due to health conditions
6) For women: Is the examinee PREGNANT
3. CONCLUSION
If "no", please explain:
Given the applicant's medical history and present mental
Yes
and physical state, is he/she fit to travel by air and study
abroad for an extended period in an intense and highly
No
demanding academic program?
Name and address of medical practitioner, including License Number
Official stamp
(please print clearly):
Date:
Signature:
Page 2 of 2
Noa Schwarzwald, Head of International Programs
International School for Agricultural Sciences, Robert H. Smith Faculty of Agriculture, Food & Environment, Herzl Street, POB 12, Rehovot, Israel
7610001
Email: [email protected]
Tel: 972-8-9489996 Fax: 972-8-9470171