外国人体格检查记录

外国人体格检查记录PHYSICALEXAMINATIONRECORDFORFOREIGNER姓Surname名Givennames性Se别口男Male:x□女Female出生日期Birthday照片必须加盖医院公章Photomustbestampedbyhospitalseal现在通讯地址Presentmailingaddress血型Bloodtype国籍Nationality出Bi生地址rthPlace过去是否患有.Have(Ez斑疹伤寒Typhusfever口小儿麻痹症Poliomyelitis口白喉Diphtheria□猩红热Scarletfever□产褥期链球菌感染Puerperalstrepto伤寒和付伤寒Typhoidandparatyph流行性脑脊髓膜炎Epidemiccerebr下列疾病（每项后面请回答“是”或“否”表示）youeverhadanyofthefollowingdiseases?ichitemmustbeanswered"Yes"or“No”）NoDYes痢疾BacillarydysenteryDNoDYesNoDYes布氏杆菌症BrucellosisDNoDYesNoDYes病毒性肝炎ViralhepatitisDNoDYesNoDYes回归热RelapsingfeverDNoDYescoccusinfectionDNoDYesloidfeverDNoDYesospinalmeningitisDNoDYes是否患有下列危及公共:Doyouhaveanyofthefollov（Ez毒物瘾Toxicomania精神错乱Mentalconfusion精神病Psychosis:躁羽妄据幻觉快序和安全的病症（每项后面请回答“是”或“否”表示）vingdiseasesordisordersendangeringthepublicorderandsecurity?ichitemmustbeanswered“Yes”or“No”）DNoDYesDNoDYes二型ManicpsychosisDNoDYesi型ParanoidpsychosisDNoDYes」型HallucinatorypsychosisDNoDYes身高厘米Heightcm体重公斤WeightKg血压毫米汞柱BloodpressuremmHg发育情况Development营养状况Nourishment颈部Neck视力Vision左L矫正视力左L眼Eyes右RCorrectedvision右R辨色力Coloursense皮肤Skin淋巴结Lymphnodes耳Ears鼻Nose扁桃体Tonsils心Heart肺Lungs腹部Abdomen

脊柱四肢SpineExtremities神经系统Nervoussystem其他所见Otherabnormalfindings胸部X线检查结果ChestX-rayExam心电图ECG化验室检查Laboratorytest艾滋病病毒抗体/Anti-HIV梅毒初筛试验/Syphilis(screen)梅毒确诊试验/Syphilis(conErmation)乙型肝炎表面抗原/HBsAg丙型肝炎抗体/Anti-HCV丙氨酸氨基转移酶/ALT(GPT)总胆红素(酶法)/TBIL天冬氨基酸转移酶/AST(GOT)未发现患有下列检疫传染病和危害公共健康的疾病Noneofthefollowingdiseasesordisordershasfoundduringthepresentexamination霍乱Cholera性病Venerealdiseases黄热病Yellowfever开放性肺结核Openinglungtuberculosis鼠疫Plague艾滋病AIDS麻风Leprosy(或HIV感染)(or