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