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Name of Applicant: Date of Birth

Y/ M/ D/

Physical Examination:

HEIGHT:

BLOOD PRESSURE:

cm

/ mmHg

WEIGHT:

PULSE RATE:

kg

/min

VISUAL ACUITY:

 R L

EYES:□normal □color anomalous □other

EAR/NOSE/THROAT:□normal □auditory meatus abnormal □cleft lip and palate 

□impending infarction □allergic rhinitis □chronic rhinitis □other

NECK:□normal □wryneck □goiter □the lymphoid swelling of gland is big □other

CHEST:□normal □thoracic anomaly □core noise □arrhythmias □other

CHEST X RAY:□normal □advertise for like the tuberculosis □pleura effusion □thoracic abnormality

□tuberculosis calcify □the spinal column side is curved up □cardiac hypertrophy

□bronchiectasis □other

ABDOMEN:□normal □hepatomegaly □splenomegaly □hernia □other

SPINAL COLUMN ARMS AND LEGS:□normal □scoliosis □frog limb □articulation deformity

□edema □other

SKIN:□normal □wart □purple plague □scabies □a dermatitis □other

MOUTH CAVITY:□normal □oral hygiene is poor □calculus □gingivitis □milk tooth □other

Urine Test:

NAD      WBC      RBC     PROTEIN       CLUCOSE    

Hepatitis B Test:

POSITIVE        

NEGATIVE        

Serological Test for Syphilis:

POSITIVE        

NEGATIVE        

HIV Test:

POSITIVE        

NEGATIVE        

THE ORIENTATION INSTITUTION WILL REQUIRE A FURTHER HIV TEST AFTER HE/SHE ARRIVES IN ROC (TAIWAN). THE ONE WITH POSITIVE TEST RESULT WILL BE REJECTED AND SENT BACK HOME IMMEDIATELY.

Pregnancy Test:

POSITIVE        

NEGATIVE        

Is the applicant now under treatment for any physical or emotional condition?

………………………………………………………………………………………………………

Do you have any recommendations for the health care of this applicant?

………………………………………………………………………………………………………

By history and physical examination, is this applicant a carrier of any communicable disease?

………………………………………………………………………………………………………

CERTIFICATION BY THE MEDICAL OFFICER:

I certify that I have examined the above applicant and in my opinion:

□ The applicant is medically fit to undertake a program in Taiwan

□ The applicant suffers mental or physical defects and is NOT in good health

 Name of physician, Title

:…………………………………………………

 Name of Hospital / Clinic

:…………………………………………………

 Address

:…………………………………………………

:…………………………………………………

:…………………………………………………

 Not valid if without the hospital or clinic’s seal

Applying for: National Pingtung University of Science and Technology (NPUST)

Master’s Program in Tropical Agriculture

INSTRUCTION:

PART 1: Personal Details and Health Declaration - to be completed by the applicant

I hereby certify that the following information is true and complete, and agree that any misrepresentation or deliberate omission of a material fact on this form may result in the withdrawal of an offer of a place or scholarship, or may result in the termination of any such offer at a future date. I hereby grant the TaiwanICDF permission to share information contained in my Medical Examination Form with relevant authorities.

X

  Signature Date

PART 2: Medical Examination - to be completed by certified physician

National Pingtung University of Science and Technology (NPUST) reserves the right to require the applicant to undergo a future medical examination after he/she arrives in the Republic of China (Taiwan).

P

PHOTO

ART 1: HEALTH DECLARATION

Nationality:

Name: (Last)

(First)

(M. Initial)

Gender: MaleFemaleDate of Birth: Y/ M/ D/

Health History:
Have you ever suffered any of the following conditions? Please mark X in appropriate box

Psychiatric illness

Epilepsy

Migraine

Asthma

Tuberculosis (PTB)

Hypertension (HPT)

Diabetes Mellitus (DM)

Heart Diseases

Malaria

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

Thyroid Diseases

Kidney Diseases

Cancer

HIV/AIDS

Venereal Diseases

Leukemia

Hemophilia

Hepatitis

Measles

German Measles (rubella)

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

Please State (if any)

Other illnesses

……………………………………………………………………………………………………….

Operation / Surgical

……………………………………………………………………………………………………….

Allergic to

……………………………………………………………………………………………………….

Family Medical History (if any)

Father:…………………………………………… Mother: ……………………………………………

Past Year Life: Please select

1. Sleep: □7~8 hours every day □Under 7~ 8 hours □Often suffer from insomnia

2. If that is basic to exercise each time for 30 minutes and 3 times every week at least, did you achieve? □No □Yes

4. Do you often feel anxious and worried? □Few or not □Sometimes □Often

5. Do you often feel the chest is stuffy? □No □Sometimes □Yes

6. Stomach-ache? □No □Sometimes □Often;. Headache? □No □Sometimes □Often

7. The menarche (girl only): (1) The age of the menarche: ______years-old

(2) Is menstrual cycle regular? □No □Yes(Date of partition ______day)

(3) Do you ever have menstrual cramp phenomenon □No □Yes

PART 2: MEDICAL EXAMINATION

Physician must complete all questions and give additional comment where necessary. Kindly note that physician is responsible for the information, suggestions and recommendation regarding the applicant’s health given in this form.

Certified original lab data need to be attached as reference.

Name of Applicant: Date of Birth

Y/ M/ D/

Physical Examination:

HEIGHT:

BLOOD PRESSURE:

cm

/ mmHg

WEIGHT:

PULSE RATE:

kg

/min

VISUAL ACUITY:

 R L

EYES:□normal □color anomalous □other

EAR/NOSE/THROAT:□normal □auditory meatus abnormal □cleft lip and palate 

□impending infarction □allergic rhinitis □chronic rhinitis □other

NECK:□normal □wryneck □goiter □the lymphoid swelling of gland is big □other

CHEST:□normal □thoracic anomaly □core noise □arrhythmias □other

CHEST X RAY:□normal □advertise for like the tuberculosis □pleura effusion □thoracic abnormality

□tuberculosis calcify □the spinal column side is curved up □cardiac hypertrophy

□bronchiectasis □other

ABDOMEN:□normal □hepatomegaly □splenomegaly □hernia □other

SPINAL COLUMN ARMS AND LEGS:□normal □scoliosis □frog limb □articulation deformity

□edema □other

SKIN:□normal □wart □purple plague □scabies □a dermatitis □other

MOUTH CAVITY:□normal □oral hygiene is poor □calculus □gingivitis □milk tooth □other

Urine Test:

NAD      WBC      RBC     PROTEIN       CLUCOSE    

Hepatitis B Test:

POSITIVE        

NEGATIVE        

Serological Test for Syphilis:

POSITIVE        

NEGATIVE        

HIV Test:

POSITIVE        

NEGATIVE        

THE ORIENTATION INSTITUTION WILL REQUIRE A FURTHER HIV TEST AFTER HE/SHE ARRIVES IN ROC (TAIWAN). THE ONE WITH POSITIVE TEST RESULT WILL BE REJECTED AND SENT BACK HOME IMMEDIATELY.

Pregnancy Test:

POSITIVE        

NEGATIVE        

Is the applicant now under treatment for any physical or emotional condition?

………………………………………………………………………………………………………

Do you have any recommendations for the health care of this applicant?

………………………………………………………………………………………………………

By history and physical examination, is this applicant a carrier of any communicable disease?

………………………………………………………………………………………………………

CERTIFICATION BY THE MEDICAL OFFICER:

I certify that I have examined the above applicant and in my opinion:

□ The applicant is medically fit to undertake a program in Taiwan

□ The applicant suffers mental or physical defects and is NOT in good health

 Name of physician, Title

:…………………………………………………

 Name of Hospital / Clinic

:…………………………………………………

 Address

:…………………………………………………

:…………………………………………………

:…………………………………………………

 Not valid if without the hospital or clinic’s seal

Applying for: National Pingtung University of Science and Technology (NPUST)

Ph.D. Program in Tropical Agriculture

INSTRUCTION:

PART 1: Personal Details and Health Declaration - to be completed by the applicant

I hereby certify that the following information is true and complete, and agree that any misrepresentation or deliberate omission of a material fact on this form may result in the withdrawal of an offer of a place or scholarship, or may result in the termination of any such offer at a future date. I hereby grant the TaiwanICDF permission to share information contained in my Medical Examination Form with relevant authorities.

X

  Signature Date

PART 2: Medical Examination - to be completed by certified physician

National Pingtung University of Science and Technology (NPUST) reserves the right to require the applicant to undergo a future medical examination after he/she arrives in the Republic of China (Taiwan).

P

PHOTO

ART 1: HEALTH DECLARATION

Nationality:

Name: (Last)

(First)

(M. Initial)

Gender: MaleFemaleDate of Birth: Y/ M/ D/

Health History:
Have you ever suffered any of the following conditions? Please mark X in appropriate box

Psychiatric illness

Epilepsy

Migraine

Asthma

Tuberculosis (PTB)

Hypertension (HPT)

Diabetes Mellitus (DM)

Heart Diseases

Malaria

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

Thyroid Diseases

Kidney Diseases

Cancer

HIV/AIDS

Venereal Diseases

Leukemia

Hemophilia

Hepatitis

Measles

German Measles (rubella)

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

Please State (if any)

Other illnesses

……………………………………………………………………………………………………….

Operation / Surgical

……………………………………………………………………………………………………….

Allergic to

……………………………………………………………………………………………………….

Family Medical History (if any)

Father:…………………………………………… Mother: ……………………………………………

Past Year Life: Please select

1. Sleep: □7~8 hours every day □Under 7~ 8 hours □Often suffer from insomnia

2. If that is basic to exercise each time for 30 minutes and 3 times every week at least, did you achieve? □No □Yes

4. Do you often feel anxious and worried? □Few or not □Sometimes □Often

5. Do you often feel the chest is stuffy? □No □Sometimes □Yes

6. Stomach-ache? □No □Sometimes □Often;. Headache? □No □Sometimes □Often

7. The menarche (girl only): (1) The age of the menarche: ______years-old

(2) Is menstrual cycle regular? □No □Yes(Date of partition ______day)

(3) Do you ever have menstrual cramp phenomenon □No □Yes

PART 2: MEDICAL EXAMINATION

Physician must complete all questions and give additional comment where necessary. Kindly note that physician is responsible for the information, suggestions and recommendation regarding the applicant’s health given in this form.

Certified original lab data need to be attached as reference.

Name of Applicant: Date of Birth

Y/ M/ D/

Physical Examination:

HEIGHT:

BLOOD PRESSURE:

cm

/ mmHg

WEIGHT:

PULSE RATE:

kg

/min

VISUAL ACUITY:

 R L

EYES:□normal □color anomalous □other

EAR/NOSE/THROAT:□normal □auditory meatus abnormal □cleft lip and palate 

□impending infarction □allergic rhinitis □chronic rhinitis □other

NECK:□normal □wryneck □goiter □the lymphoid swelling of gland is big □other

CHEST:□normal □thoracic anomaly □core noise □arrhythmias □other

CHEST X RAY:□normal □advertise for like the tuberculosis □pleura effusion □thoracic abnormality

□tuberculosis calcify □the spinal column side is curved up □cardiac hypertrophy

□bronchiectasis □other

ABDOMEN:□normal □hepatomegaly □splenomegaly □hernia □other

SPINAL COLUMN ARMS AND LEGS:□normal □scoliosis □frog limb □articulation deformity

□edema □other

SKIN:□normal □wart □purple plague □scabies □a dermatitis □other

MOUTH CAVITY:□normal □oral hygiene is poor □calculus □gingivitis □milk tooth □other

Urine Test:

NAD      WBC      RBC     PROTEIN       CLUCOSE    

Hepatitis B Test:

POSITIVE        

NEGATIVE        

Serological Test for Syphilis:

POSITIVE        

NEGATIVE        

HIV Test:

POSITIVE        

NEGATIVE        

THE ORIENTATION INSTITUTION WILL REQUIRE A FURTHER HIV TEST AFTER HE/SHE ARRIVES IN ROC (TAIWAN). THE ONE WITH POSITIVE TEST RESULT WILL BE REJECTED AND SENT BACK HOME IMMEDIATELY.

Pregnancy Test:

POSITIVE        

NEGATIVE        

Is the applicant now under treatment for any physical or emotional condition?

………………………………………………………………………………………………………

Do you have any recommendations for the health care of this applicant?

………………………………………………………………………………………………………

By history and physical examination, is this applicant a carrier of any communicable disease?

………………………………………………………………………………………………………

CERTIFICATION BY THE MEDICAL OFFICER:

I certify that I have examined the above applicant and in my opinion:

□ The applicant is medically fit to undertake a program in Taiwan

□ The applicant suffers mental or physical defects and is NOT in good health

 Name of physician, Title

:…………………………………………………

 Name of Hospital / Clinic

:…………………………………………………

 Address

:…………………………………………………

:…………………………………………………

:…………………………………………………

 Not valid if without the hospital or clinic’s seal

Attachment 2

Application Document Checklist

※Please mark “” in the space after confirming the Required Documents.

※Please put this checklist in front of all other Required Documents.

Mark “

Required Documents

報名表

Completed application form

經我國駐外館處等驗證之外國學校最高學歷畢業證書影本

Photocopy of the highest degree diploma verified with official stamps by the ROC (Taiwan) Embassy in the country of the issuing school

經我國駐外館處等驗證之外國學校最高學歷成績單證明正本

Official transcript verified with official stamps by the ROC (Taiwan) Embassy in the country of the issuing school

最近三個月內之健康檢查報告

TaiwanICDF Medical Report within 3 months

推薦信三封

Three recommendation letters

英文留學計畫書一份

One study plan/proposal in English

英文能力證明(英語系國家申請者除外)

Evidence of English proficiency, excluding applicant whose native language is English

護照影本一份

One photocopy with personal information page of the passport

其他相關文件

Other documents related to the application




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