外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
姓 名 Name |
| 性别 男Male Sex 女Female | 出生日期 ____年___月___日 Date of Birth y.___m.___d.___ | 照片 Photo (Put ospital seal across the photo) |
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现在通迅地址 Present mailing adderss |
| 血型 Blood Type |
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国籍
Natio-
nality
出生地
Birth
Place
过去是否患有下列疾病：(每项后面请回答“否”或“是”)
No |
Yes |
No |
Yes |
Have you ever had any of the following diseases?(Each ietm must be answered “Yes”or “No”
No |
Yes |
No |
Yes |
斑疹伤寒 Typhus fever 细菌性痢疾Bacillary dysentery
No |
Yes |
No |
Yes |
小儿麻痹症 Poliomyelitis 布氏杆菌病 Brucellosis
No |
Yes |
No |
Yes |
白 喉 Diphtheria 病毒性肝炎 Viral hepatitis
No |
Yes |
No |
猩 红 热 Scarlet fever 产褥期链球菌 Puerperal streptococcus
No |
Yes |
Yes |
回 归 热 Relapsing fever 感 染 Infection
No |
Yes |
伤寒和副伤寒 Typhoid and paratyphoid fever
流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis
是否患有下列危及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 secure?
No |
Yes |
(Each item most be answered “Yes” or “No”)
No |
Yes |
毒物瘾 Toxicomania····················································
No |
Yes |
精神错乱 Mental confusion ···············································
No |
Yes |
精神病Psychosis：躁狂型 Manic psychosis ·······························
No |
Yes |
妄想型 Paranoid psychosis ······························
幻觉型 Hallucinatory psychosis ··························
身 高/Height(厘米/cm)
体 重/Weight(公斤/kg)
血压/Pressure Blood(毫米汞柱/mmHg)
发育情况 Development
营养情况 Nourishment
颈部 Neck
视 力
Vision
左L
右R
矫正视力
Corrected
vision
左L
右R
眼Eyes
辨色力/Color sense
皮肤/Skin
淋巴结/Lymph nodes
耳/Ears
鼻/Nose
扁桃体/Tonsils
心/Heart
肺/Lungs
腹部/Abdomen
脊柱/Spine
四肢/Extremities
神经系统/Nervous system
其他所见
Other abnormal findings
胸部X线检查/Chest
X-ray exam
心电图/ECG
化验室检查(包括艾滋病、梅毒血清学诊断)/
Laboratory Exam(HIV, Syphilis Serodiagnosis)
附上对以下项目的化验室报告：Please attach the results and data sheets for the following items:AIDS.,Syphilis,ALT.,AST.,T-BIL.,and HbsAG.
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 following diseases or disorders found during the present examination
霍 乱 Yholera 性 病 Venereal Disease
黄热病 Yellow fever 开放性肺结核 Opening 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 Date