外国人体检表

1、.外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓 名Name性别 男MaleSex 女Female出生日期 _年_月_日Date of Birth y._m._d._照片Photo(Put ospitalseal across the photo)现在通迅地址Present mailing adderss血型Blood Type国籍Natio-nality出生地BirthPlace过去是否患有下列疾病：(每项后面请回答“否”或“是”)NoYesNoYesHave you ever had any of the following dise

2、ases?(Each ietm must be answered “Yes”or “No”NoYesNoYes斑疹伤寒 Typhus fever 细菌性痢疾Bacillary dysenteryNoYesNoYes小儿麻痹症 Poliomyelitis 布氏杆菌病 BrucellosisNoYesNoYes白 喉 Diphtheria 病毒性肝炎 Viral hepatitisNoYesNo猩 红 热 Scarlet fever 产褥期链球菌 Puerperal streptococcusNoYesYes回 归 热 Relapsing fever 感 染 InfectionNoYes伤寒和副伤

3、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?NoYes(Each item most be answered “Yes” or “No”)NoYes毒物瘾 ToxicomaniaNoYes精神错乱 Mental confusion

4、NoYes精神病Psychosis：躁狂型 Manic psychosis NoYes 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Correctedvision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/H

5、eart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/ChestX-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 Lepro