Certificate of Medical Examination (See Note 4) NAGASAKI UNIVERSITY
1-14 Bunkyo-machi, Nagasaki City 852-8521, Japanyrs( )hrs after meal
( )hrs after meal
1. Normal
2.Abnormal
R ( )
L ( )
1000Hz 1. Normal 2. Abnormal
4000Hz 1. Normal 2. Abnormal
1000Hz 1. Normal 2. Abnormal
4000Hz 1. Normal 2. Abnormal
A. Normal
B. Follow-up required
Film No. C. Further testing required*
1.Normal D. Treatment required*
2.Abnormal( ) E. Currently being treated**( )
*C & D: Submit associated test results with this form.
**E: Describe treatment in space provided.
1.Able to work
2.Unable to work
Examination date: Day Month Year (See Note 3)
Examining facility
Signature of examining physicianAgeName
Sex M / F
Date of Birth
(dd/mm/yyyy)
___ /___ /_____
day mo year
Employment
history
Blood pressure mmHg /
Hematological
examination
Red blood
cell coun×ばつ104/mm3
Past medical
history
Hemoglobin g/dl
Liver function
AST IU/L
ALT IU/L
γ-GTP IU/L
mg/dl
HDL-C mg/dl
Subjective
symptoms
Triglyceride mg/dl
Blood glucose
(see Note 1)
FPG mg/dl
Random
Present
illnesses
and/or
treatment Serum lipids
LDL-C
mg/dl
Height (cm)
Urinalysis
Proteinuria
Weight (kg) GlucosuriaBMIElectrocardiography
Waist
circumference(cm)Vision
Other testing
(see Note 2)
HearingRL
Exam findings
Chest
X-ray Examining physician
remarks
Direct/Indirect
Date of X-ray examination
Day Month Year .
【2020年12月1日改訂版】
Note 1: For blood glucose testing, perform a fasting or random (casual) plasma glucose test. To the extent possible, avoid drawing blood less than 3.5 hours
after the start of the most recent meal.
Overall assessment
Note 2: "Other testing" refers to a fecal (stool) culture, which is performed in the case of food service workers employed in school or hospital
cafeterias/kitchens.
Note 3: This examination should be performed no more than 3 months prior to employment start date.
Note 4: Be sure to get a regular employee medical examination within one year of getting this pre-employment examination.