外國人體格檢查表FOREIGNERPHYS

1、外國人體格檢查表FOREIGNER PHY SICAL EXAMINATION FORM姓名Name性別Sex男 Male女 Female出生日期Birth Day -Month - Year照片(加蓋檢查 單位印章)Photo (stamped Official stamp)現(xiàn)在通信地址Prese nt maili ng address血型國籍或地區(qū)Nationality(or Area)出生地址Birth PlaceBlood type過去是否患有下列疾?。?每項后面請回答“否”或“是”)Have you ever had any of the follow ing deseases?(E

2、ach item must be answered Yes" or No")斑 疹傷寒 Typhus fever NoD Yes菌痢 Bacillary dyse ntery NQ Yes小兒麻痹癥PoliomyelitisNoD Yes布氏桿菌病BrucellosisNoD Yes白喉DiphtheriaNoD Yes病毒性肝炎Viral hepatitisNoD Yes猩 紅 熱Scarlet feverNoD Yes產(chǎn)褥期鏈球Puerperal streptococcus in fectio n回 歸熱 Relapsing fever NoD Yes菌感染 NoD Y

3、es傷寒和付傷寒 Typhoid and paratyphoid feverD NoD Yes流行性腦脊髓膜炎Epidemic cerebrospi nal me nin gitisD NoD Yes是否Do you have ar (Each item mus 毒物癮 Tox患有下列危機公共秩序和安全的病癥：(每項后面請回答“否”或“iy of the follow ing diseases or disorders endan geri ng the public order an ;t be answered Yes" of No ”)是”)d security? NoD Ye

4、s-D NoD YesD NoD YesD NoDYesD NoD Yesicomania精神錯口UIVIDldl J5HU55I精神病 Psychosis:躁狂型 Manic Paychosis妄想型 Paranoid psychosis幻想型 Hallucinatory psychosis 身高厘米HeightCM體重公斤Weightkg血壓毫米水柱Blood pressuremmHg發(fā)育情況Developme nt營養(yǎng)情況Nourishme nt頸部Neck視力左LVision右 R矯正視力左LCorrected vision右 R眼Eyes辨色力Colour sen ses皮膚Ski

5、n淋巴結(jié)Lymph no des耳Ears鼻Nose扁桃體Ton sils心肺腹部HeartLun gsAbdome n脊柱四肢神經(jīng)系統(tǒng)Spi neExtremitiesNervous system其它所見Other abno rmal findings胸部X線 檢查結(jié)果 (附檢查報告單)Chest X-ray Exam (attached chest X-ray report)心電圖ECG化驗室檢杳 (包括艾滋病、梅 毒等血清學(xué)檢杳)Laboratory exam (Attached test report of AIDS,Syphilis etc)未發(fā)現(xiàn)患有下列檢疫傳染病和危害公共健康的疾?。篘one of the follow ing diseases of disorders found duri ng the prese nt exam in ati on.霍舌 LCholera性病Ven ereal Disease黃熱病Yellow fever肺結(jié)核Lung tuberculosis鼠疫Plague艾滋病AIDS麻風(fēng)