境外人员体格检查记录

1、境外人员体格检查记录YesPHY SICAL EXAMINATION RECORD FOR FOREIGNER斑疹伤寒 小儿麻痹症 白 猩 回Typhus feverPoliomyelitis DiphtheriaScarlet feverNo No No No No No Yes No Yes No YesYes 产褥期链球菌 Puerperal streptococcus infectionYes菌Yes布氏杆菌病Yes病毒性肝炎痢 Bacillary dysentery BrucellosisViral hepatitisYes 感染 No YesRelaps ing fever 伤寒和

2、付伤寒Typhoid and paratyphoid fever No Yes流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis No Yes姓名Name性别Sex男 Male 女 Female出生日期Date of Birth Day/Mo nth/Year照片Photo现在通讯Prese ntu地址address血型Blood type国籍Nati on ality出生地址Birth Place过去疋否患有以下疾病内.(每项丿口面请答复 疋 或 否)Have you ever had any of the follow ing diseases? (Eac

3、h item must be an swereda K |or No是否患有以下危及公共秩序和平安的病症：(每项后面请答复“是或“否)Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered“Yes or “No)毒物瘾 Toxicomania 精神错舌 L Men talc on fusi on 精神病 Psychosis:躁狂型 Manic psychosis 妄想型 Paranoid psycho

4、sis 幻觉型 Hallucinatory psychosis 厘米cmNoYesNoYesNoYesNoYesNoYes身高Height 发育情况Developme nt 视力左 LVisio n 右 R辨色力Colour sense耳Ears心Heart编号：42 (19X27 cm)体重Weight营养情况Nourishme nt矫正视力 左 LCorrected Visio n 右 R 皮肤Ski n鼻Nose肺Lungs公斤kg血 压Blood pressure 颈部Neck眼Eyes 淋巴结Lymph no des扁桃体Ton sils腹部Abdome n毫米汞柱mmHg脊柱四肢S

5、pi neExtremities神经系统Nervous system其他所见Other abno rmal findings肺部X线 检杳Chest X-ray Exam.心电图ECG化验室检杳包括血清学诊断Laboratory Exam.(Serodiag no sis)未发现患有以下检疫传染病和危害公共健康的疾病：None of the follow ing diseases or disorders found duri ng the prese nt exam in atio n霍乱Cholera性病Venereal Disease黄热病 Yellow fever开放性肺结核 Opening lung tuberculosis鼠疫Plagus艾滋病AIDS麻风Lepro