Health Certificate Page 1

Please be careful. All incomplete documents will be returned.

1. Write Your name, Gender, Date of Birth, Current Address
2. Ask your physician or Health Care Provide fill following fields
3. Physical Examination: Date, Height, Weight, Blood Pressure, Pulse, Urinalysis-Protein, Blood, Sugar - Positive or Negative-
4. Medical, surgical or psychiatric conditions in the past? Yes or No
5. Medical, surgical or psychiatric conditions in present? Yes or No
6. Allergies o food or medications? Yes or No.
7. Recommendations regarding travel/study abroad

Please do not forget to have Physician's name, Official stamp, signature and date to complete.