For International Students/Researchers
Gifu University is providing a healthy and safe campus according to the School
Health and Safety Act and the Occupational Health and Safety Act. For infection
control and accommodation services, we require all participants to provide
individual health information.
Please submit attached CERTIFICATE OF HEALTH completed by a physician, andissued by a medical institute.
Notice:1. If you require special support or accommodation, please describe in detail.
2. Measles, rubella, mumps, and chicken pox are highly contagious. To prevent
outbreaks on campus, all of the population must have adequate levels ofimmuno-defense power (antibody titers) for each infectious disease. If you have aprevious history of infection or vaccination, please fill out the onset date or dateof the shot. If you have no idea, measure your antibody titer with blood analysis
and fill out the form attached. If the titer is insufficient, please have anadditional vaccination and fill out the vaccination information.

The Health Administration Center is a support center provided to ensure a
comfortable life at the university. The center provides first aid and healthpromotion, as well as consultations for physical and mental concerns. If you have
any worries or concerns, please do not hesitate to contact us.
Personalhealthinformationisneverdistributed

outsidetheHealthAdministration Center without your permission, except in a life-threatening
emergency. Your health information will be used only for the purpose of healthsupport and administration. You will never experience any disadvantages related
to providing the health information.
Gifu University Health Administration Center,
E-mail: hokencen@gifu-u.ac.jp

TEL: +81(0)58-293-2174

URL: http://www.hoken.gifu-u.ac.jp

FAX: +81(0)58-293-2177

CERTIFICATE OF HEALTH (to be completed by the examining physician)Please fill out (PRINT/TYPE) in English and mark  in appropriate □ by a physician.
Name (Full spell):□Male□Female

Date of Birth:Age:
1. Physical Examination(1) Height:cm

Weight:(2) Blood pressure:kg
mm/Hg～(3) Eyesight: (R)(L)

Pulse: □regular□irregular□without □With glasses or contact lenses(4) Hearing:□normal □impaired(5) S p e e c h:□normal □impaired(6) L u n g s:

□normal □impaired(7) H e a r t:

□normal □impaired →Electrocardiograph ()2. Chest X-ray examinations
Date(within 3 months)

Describe the condition of applicant's lungs: (3. Urinalysis : glucose ()protein ()occult blood ())

4. Past history or present illness□ Tuberculosis□ Malaria□ Other infectious disease□ Epilepsy□ Psychosis□ Kidney disease□ Heart disease□ Lung disease□ Gastrointestinal disease□ Thyroid disease□ Collagen disease□ Diabetes mellitus□ Drug allergy□ Food allergy□ Others (5. Under medical treatment at present : □No
Conditions/particulars ()□Yes)

Physical disability : □No □Yes
Conditions/particulars ()6. Status of immunization
Indicate the date of vaccine, a physician documented history, or serologic evidence of immunity.
Varicella / Chicken pox : History of onset : Date of diagnosis (Serum Antibody Titer :)(dateDate of vaccination : Date 1 ()) Date 2 ()Rubella : History of onset : Date of diagnosis ()Serum Antibody Titer :(dateDate of vaccination : Date 1 ()) Date 2 ()Measles : History of onset : Date of diagnosis ()Serum Antibody Titer :(dateDate of vaccination : Date 1 ()) Date 2 ()Mumps : History of onset : Date of diagnosis ()Serum Antibody Titer :(dateDate of vaccination : Date 1 ()) Date 2 ()[For students / researchers with field work activities]
Tetanus : Date of vaccination : Date () (within 5 Years)[For students / researchers with medical field activities]
Hepatitis B : Serum Antibody Titer :Date of vaccination : Date 1 ((date) Date 2 () Date 3 (7. The applicant's health status is adequate to pursue studies in Japan.
□ YES

□ NO

8. Additional comments. If he/she needs special supports, please describe in detail.

Physician’s Signature :Date :

Physician's Name (Print) :Office/Institution :Address :Phone :
E-mail address :Fax :))