外国人体格检查表FOREIGNERPHYS

1、外国人体格检查表FOREIGNER PHY SICAL EXAMINATION FORM姓名Name性别Sex男 Male女 Female出生日期Birth Day -Month - Year照片(加盖检查 单位印章)Photo (stamped Official stamp)现在通信地址Prese nt maili ng address血型国籍或地区Nationality(or Area)出生地址Birth PlaceBlood type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 follow ing deseases?(E

2、ach item must be answered Yes" or No")斑 疹伤寒 Typhus fever NoD Yes菌痢 Bacillary dyse ntery NQ Yes小儿麻痹症PoliomyelitisNoD Yes布氏杆菌病BrucellosisNoD Yes白喉DiphtheriaNoD Yes病毒性肝炎Viral hepatitisNoD Yes猩 红 热Scarlet feverNoD Yes产褥期链球Puerperal streptococcus in fectio n回 归热 Relapsing fever NoD Yes菌感染 NoD Y

3、es伤寒和付伤寒 Typhoid and paratyphoid feverD NoD Yes流行性脑脊髓膜炎Epidemic cerebrospi nal me nin gitisD NoD Yes是否Do you have ar (Each item mus 毒物瘾 Tox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“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精神错口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体重公斤Weightkg血压毫米水柱Blood pressuremmHg发育情况Developme nt营养情况Nourishme nt颈部Neck视力左LVision右 R矫正视力左LCorrected vision右 R眼Eyes辨色力Colour sen ses皮肤Ski

5、n淋巴结Lymph no des耳Ears鼻Nose扁桃体Ton sils心肺腹部HeartLun gsAbdome n脊柱四肢神经系统Spi neExtremitiesNervous system其它所见Other abno rmal findings胸部X线 检查结果 (附检查报告单)Chest X-ray Exam (attached chest X-ray report)心电图ECG化验室检杳 (包括艾滋病、梅 毒等血清学检杳)Laboratory exam (Attached test report 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：None 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黄热病Yellow fever肺结核Lung tuberculosis鼠疫Plague艾滋病AIDS麻风