CERTIFICATE OF HEALTH
Name ：
Hermansyah
(Family name) (First name) (Middle name)
Sex ：
□ Male □
Female Date of Birth ：
15 Mei 1995
Present Address ：
Kp. Sumur Kopo
Ds. Taktakan Kec. Taktakan Kota. Serang. Provinsi. Banten
1) Height ：
169
cm Weight ： 50
kg
2) Blood Pressure ：
Normal /
mmHg
Visual
acuity ：
（R）Normal （L）
Normal
〔（R）
No （L）
No 〕
without glasses 〔with
glasses or contact lenses〕
Hearing ： （R）□
Normal □
Abnormal
（L）□
Normal □
Abnormal
3) History of past illness ：
( No .)
4) Present condition of health ：
( Healthy,
)
5) Physical examination of the applicant’s
lungs and the result of chest X-ray with the date.
(I do not understand.)
6) The applicant’s health and physical
condition ： ( Good )
□
Examination □
Good □
Fair □
Poor
Date
of Examination ：26 Agustus 2014
Signature ：
Name and title of
Physician (Please print) ：
Institution and
address ：kebon jahe, serang-banten
