外国人体格检查表

1、附件 6外 国 人 体 格检查表FOREIGNER PHYSICAL EXAMINATION FORM姓名Name性别Sex男 Male女 Female出生日期Birth Day Month - Year照 片现在通信地址Present mailing address 血型(加盖检查单位印章 )国籍或地区Nationality (or Area)出生地址Birth PlaceBlood type Photo(stampedOfficial stamp)过去是否患有下列疾病： （每项后面请回答“否”或“是” ）Have you ever had any of the following dese

2、ases?(Each item must be answered “Yes”or “No ”)斑 疹伤寒 Typhus fever N o Yes 菌 痢 Bacillary dysentery NoYes小儿麻痹症 Poliomyelitis N o Yes 布氏杆菌病 Brucellosis NoYes白 喉 Diphtheria N o Yes 病毒性肝炎 Viral hepatitis NoYes猩红热Scarlet fever N o Yes产褥期链球 Puerperal streptococcus infection回归热Relapsing fever N o Yes 菌 感 染

3、NoYes伤寒和付伤寒 Typhoid and paratyphoid fever NoYes流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis No Yes是否患有下列危机公共秩序和安全的病症： （每项后面请回答“否”或“是” ）Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered “Yes”of “No”)毒物瘾Toxicomania NoYes精神错乱 Met

4、al confusion NoYes精神病 Psychosis：躁狂型 Manic Paychosis NoYes妄想型 Paranoid psychosis NoYes幻想型 Hallucinatory psychosis NoYes 体重 公斤 血压毫米汞柱身高 厘米Height CM Weight kg Blood pressure mmHg 营养情况颈部发育情况Development Nourishment Neck 视力 左 L_矫正视力 左 L_眼Vision 右 R Corrected vision 右 R Eyes辨色力 皮肤 淋巴结Colour senses Skin Lym

5、ph nodes耳 鼻 扁桃体Ears Nose Tonsils心 肺 腹部Heart Lungs Abdomen脊 柱 四 肢 神经系统Spine Extremities Nervous system其它所见Other abnormal findings胸部 X 线检查结果（附检查报告单）心电图Chest X-rayECG Exam(attached chest X-rayreport)化验室检查（包括艾滋病、梅毒等血清学检查）Laboratory exam (Attached testreport of AIDS,Syphilis etc)未发现患有下列检疫传染病和危害公共健康的疾病：No

6、ne of the following diseases of disorders found during the present examination.霍 乱 Cholera 性 病 Venereal Disease黄热病 Yellow fever 肺结核 Lung tuberculosis鼠 疫 Plague 艾滋病 AIDS麻风Leprosy 精神病 Psychosis意见检查单位盖章Suggestion Official Stamp医师签字 日期Signature of physician DateThe foreigners are supposed to take the ph

7、ysical examination before leaving in a national or regional public hospital andget report of all the items listed in the form with the signature of the doctor and the stamp of the hospital. If the check isdone in a private hospital or clinic, the report should be notarized by a public notary. The fo

8、rm submitted should be theoriginal copy with the photo of the examinee and supporting documentations such as laboratory report sheets,X-ray films and necessary testing reports.The Administration of Quality supervision, Inspection and Quarantine will double check the submitted form and attacheddocumentations upon their arrival and decide whether it's acceptable or they should take additional or another physicalexamination. If additional check or re-check is required, the student should