沈阳师范大学ShenyangNormalUniversity

1、外国人体格检查记录PHY SICAL EXAMINATION RECORD FOR FOREIGNER过去是否患有以下疾病：(每项后面请答复：“否或“是)Have you ever had any of the follow ing diseases?(Each item must be answered “ Yes斑疹伤寒Typhus fever No Yes菌痢Bacillary dyse ntery No Yes小儿麻痹症Poliomyelitis No Yes布氏杆菌病Brucellosis No Yes白喉Diphtheria No Yes病毒性肝炎Viral hepatitis N

2、o Yes猩红热Scarlet fever No Yes回归热Relaps ing fever No Yes No No No Yes Yes YesPuerperal streptococcus infection Typhoid and paratyphoid fever Epidemic cerebrosp inal menin gitis产褥期链球菌感染 伤寒和付伤寒流行性脑脊髓膜炎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“否或“是)Do you have any of the follow ing diseases or disorders endan

3、 geri ng the public order and security? (Each item must be an swered“ Yes or“ No)Toxicoma nia毒物瘾精神错乱精神病 Psychosis：Me ntal Con fusi on躁狂型妄想型幻觉型身高Height发育情况厘米cmDevelopme nt视力左LVision 右 R辨色力Colour sense耳EarsHeartMan ic psychosisPara noid psychosisHallucinatory psychosis千克Weight营养情况Nourishme nt左LCorrect

4、ed vision 右 R矫正视力Ski n鼻NoseLungsKgBlood pressure颈部NeckEyes 淋巴结Lymph no des 扁桃体Ton silsAbdome n No Yes No Yes No Yes No Yes No Yes千帕Kpa姓名Name性别Sex男 Male女 Female岀生日期Birth Day-Month-Year昭八、片Photo(StampedOfficial Stamp )现在通讯地址Prese nt maili ng address血型Bloodtype国籍Natio nality出生地址Birth Place脊柱Sp ine四肢Ext

5、remities神经系统Nervous system其它所见Other abno rmal findings胸部X线检查Chest X -ray exam.心电图ECG化验室检杳包括艾滋病、 梅毒血清学诊断Laboratory exam.(HIV, Syphilis 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 ati on.霍舌 LCholera性病 Ven ereal Disease黄热病 Yellow fever开 放性肺 结核Opening lung tuberculosis鼠疫Plague艾滋病AIDS麻风Lepro