外国人体检报告

1、.外 国 人 体 格 检 查 表FOREIGNER PHYSICAL 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)现在通讯地址Present mailing address血型Blood type国籍或地区Nationality(or Area)出生地址Birth Place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 following diseases?(Ea

2、ch item must be answered “Yes” or “No”)斑疹伤寒小儿麻痹症白喉猩红热回归热Typhus fever PoliomyelitisDiphtheriaScarlet feverRelapsing feverNo YesNo YesNo YesNo YesNo Yes菌痢布氏杆菌病病毒性肝炎产褥期链球菌感染Bacillary dysenteryBrucellosisViral hepatitisPuerperal streptococcus infection No YesNo YesNo YesNo YesNo Yes伤寒和付伤寒流行性脑脊髓膜炎 Typhoi

3、d and paratyphoid feverEpidemic cerebrospinal meningitisNo YesNo Yes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 security?(Each item must be answered “Yes” or “No”)毒 物 瘾精神错乱Toxicomania.Mental confusionNo Yes No Yes精 神 病Psy

4、chosis躁狂型 Manic Paychosis.妄想型 Paranoid Psychosis幻觉型 Hallucinatory PsychosisNo YesNo YesNo Yes身高 厘米Height cm体重 公斤Weight kg血压 毫米汞柱Blood pressure mmHg发育情况Development营养情况Nourishment颈部Neck视力 左 L Vision 右 R 矫正视力 左 L Corrected Vision 右 R 眼Eyes辩色力Colour sense皮肤Skin淋巴结Lymph nodes耳Ears鼻Nose扁桃体Tonsils心Heart肺Lu

5、ngs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线检查结果（附检查报告单）Chest X-rayExam(Attached chest X-ray report)心电图ECG化验室检查（包括艾滋病、梅毒等血清学检查）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 following diseases of disorders found during the present examination.霍 乱黄热病鼠 疫麻 风CholeraYellow fever PlagueLeprosy性 病肺结核艾滋病精神病Venereal DiseaseLung tuberculo