赴美移民體檢申請單預防接種申請單PDF版

注意事項：以下內容請以電子版形式準確填寫，所有項目均須回答，不得留空（男性申請人不用回答５．６兩題）。經核對無誤后請打印此表格并親筆簽名，體檢當日必須將此表格提交前臺登記。所有信息一經提交后不得更改，如申請人提交不實信息或填寫錯誤，所造成后果由申請人本人負責。赴美移民人員健康檢查申請表PHYSICALEXAMINATIONRECORDFORIMMIGRANTTOUS年齡（周歲）Age簽證類型VisaCategory姓名出生日期性別FullNameBirthDateGender面談日期護照號碼檔案號碼InterviewDatePassportNoCaseNo國籍出生地婚姻狀況NationalityBirthPlaceMaritalStatus現居住國原居住國電話號碼PresentCountryPriorCountryTelephone居住地址（英文）PresentAddress郵政編碼電子郵箱PostalCodeE-mail美國地址（英文）USAddress在美居住城市在美居住州美國郵編（英文全稱）（英文全稱）（英文）USCityUSStateUSPostalCode1.您是否做過赴美移民體檢？（請?zhí)顚憽笆恰被颉胺瘛?/p>

）Haveyoutakentheimmigrationhealthcheckoncebefore

？（Pleaseanswer

‘Yes）’

or

‘No’2.上次移民體檢日期

Lastdateofimmigrationhealthcheck3.最近七天內您是否發(fā)熱和咳嗽？（請?zhí)顚憽笆恰被颉胺瘛?）Doyouhavecoughorfeverwithinlastweek？（Pleaseanswer ‘Yes）’or ‘No’4.您是否得過肺結核？（請?zhí)顚憽笆恰被颉胺瘛?）DoyouhavehistoryofTuberculosis？（Pleaseanswer ‘Yes）’or ‘No’（5-6題僅針對女性

No.5,6:Femaleapplicantsonly.

）5.末次月經開始日期

(月-日-年)Lastmenstrualperiod(mm-dd-yyyy)6. ?Areyoupregnantnow? （Pleaseanswer

‘Yes）’

or

‘No’本人已校對確認個人資料無誤，并對填報的信息負責。IdeclarethattheinformationIhaveprovidedaboveistothebestofmyknowledgeandtrue.申請人/監(jiān)護人簽名（請打印此表格并親筆簽名）Signatureofapplicant/guardian 日期Date注：18周歲及以上申請人請打印本頁表格，如實填寫并親筆簽名。預防接種預防接種聯系電話（周一至周五8：00-15：30,國定假日除外）

預防接種申請單 BJZ-048021-62686428021-63295026Tel:(MondaytoFriday8:00-15:30, Nationalholidaysexcluded ):A預防接種記錄單 BJZ-048注：未滿18周歲的申請人請打印本頁表格，如實填寫并由法定監(jiān)護人簽名。預防接種申請單 未成年人(<18歲) BJZ-048ApplicationFormandScreeningQuestionnaireforChildrenandAdolescentsImmunization(<18years)Isyourchildsicktoday?Hasyourchildeverhadaseriousreactionafterreceivingavaccination?Doesthechildhaveallergiestomedications,food(eggsect.),oranyvaccine?Hasyourchildreceivedany vaccinationsinthepastfourweeks?Doesyourchild,oranypersonwholiveswithortakescareofhim/her,havecancer,leukemia,AIDS,oranyotherimmunesystemproblem?Isyourchild,oranypersonwholiveswithortakescareofhim/her,takingcortisone,prednisone,othersteroids,anticancerdrugs,orradiation treatments?DuringthepastOneyear,hasyourchildreceivedatransfusionofbloodorplasma,oranytreatmentofimmunoglobulin?Doesyourchildhaveepilepsiaoranyotherneuropsychicalsystemproblems?作 記 Doesyourchildhaveanyofthefollowingdiseases?或帶狀皰疹是否隨身帶有過去曾經接種疫苗的預防接種記錄？ Doyoubringyourchild ’svaccinationrecordwithyou?家長/監(jiān)護人簽名 /Signatureofparent/guardian聯系電話（周一至周五8：00-15：30,國定假日除外）021-62686428021-62686187021-63295026Tel:(MondaytoFriday8:00-15:30,Nationalholidaysexcluded):