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[Hanawaro]

1)What serious diseases, injuries and/or medical conditions have you had in the past five years? If any of these resulted in hospitalisation, please give details as to when, why, and the duration of treatment below AND have your doctor fill out the Statement of Physician.

2)Оther than those stated in 1)., have you ever been treated for any other serious diseases, injuries, and/or medical conditions, including heart disease, blood disease, auto immune disease, cancer, epilepsy, congenital disease, recurrent disease, carrier conditions (for example, hepatitis), or any other disease, injury, or medical condition involving permanent damage? If yes, you must provide details below AND have your doctor fill out the Statement of Physician.

3)Have you ever suffered from any nervous or mental disorders? (including, but not limited to anxiety, depression, ADD, ADHD, eating disorders, etc.). If yes, you must provide details below AND have your doctor fill out the Statement of Physician. Please note that we may contact your doctor if further information is necessary.

4)Do you foresee any physical challenges resulting from the need to go up and down several flights of stairs on a daily basis? If yes, please explain.

5)Please explain any other health-related issues or disabilities below (e.g. legally blind, hearing impaired, colour blindness, confined to wheelchair, pending medical treatment, etc.).