外国人体格检查表

1、附件6外国人体格检查表for曰gner physical examination form姓名name性别sex口男male出生日期女 female birth day - month - year照片(加盖检查 单位印章)photo (stamped official stamp)现在通信地址present mailing address血型 blood type国籍或地区nationality (or area)出生地址birth place过去是否患后卜列疾病：(每项后面请回答“否”或“是”)have you ever had any of the following deseases?

2、(each item must be answered yes or no)斑 疹伤寒 typhus fever nod yes菌痢 bacillary dysentery nod yes小儿麻痹症poliomyelitis no yes布氏杆菌病brucellosis nod yes白喉 diphtheria nd yes病毒性肝炎viral hepatitisdnod yes猩 红 热scarlet fever nd yes产褥期链球puerperal streptococcus infection回归热relapsing fever nod yes菌感染口 nod yes伤寒和付伤寒 t

3、yphoid and paratyphoid fever nod yes流行性脑脊髓膜炎epidemic cerebrospinal meningitis nod yes是do you have an (each item mus 毒物瘾 toxi蛙山友住不in/i否患后卜列危机公共秩序和安全的病症：(每项后面请回答“否”或然y of the following diseases or disorders endangering the public order and se t be answered yes of no) ) curity? nod yes nod yes nd yes n

4、od yes nod yescomania1 日 1甲口 口livietaiconiusion精神病psychosis：躁狂型 manic paychosis妄想型 paranoid psychosis 幻想型 hallucinatory psychosis 身高厘米heightcm体重公斤weightkg血压室米水柱blood pressuremmhg发育情况development营养情况nourishment颈部neck视力左lvision右 r矫正视力左lcorrected vision 右 r眼eyes辨色力colour senses皮肤skin淋巴结lymph nodes耳ears鼻

5、nose扁桃体tonsils心heart肺lungs腹部abdomen脊柱四肢神经系统spineextremitiesnervous system其它所见other abnormal findings胸部x线 检查结果 (附检查报告单)chest x-ray exam (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)未发现患后卜列检疫传染病和危害公共健康的疾病：none of the following di

6、seases of disorders found during the present examination.霍舌 lcholera性病venereal disease黄热病yellow fever肺结核lung tuberculosis鼠疫plague艾滋病aids麻风leprosy精神病psychosis意见检查单位盖章suggestionofficial stamp医师签字日期signature of physiciandatethe foreigners are supposed to take the physical examination before leaving in

7、a national or regional public hospital and get report of all the items listed in the form with the signature of the doctor and the stamp of the hospital. if the check is done in a private hospital or clinic, the report should be notarized by a public notary.the form submitted should be theoriginal c

8、opy with the photo of the examinee and supporting documentations such as laboratory report sheets, x-ray films and necessary testing reports.the administration of quality supervision, inspection and quarantine will double check the submitted form and attached documentations upon their arrival and decide whether its acceptable or they should take additional or another physical examination. if additional check or re-check is required, the student should fo