外国人体格检查记录

1、外国人体格检查记录PHY SICAL EXAMINATION RECORD FOR FOREIGNER姓名Name性别 男Male Sex女Female出生年月Birth Day Mon thYear国籍Natio nality出生地Birth Place血型Blood Type现在通讯地址Present mailing address照片photo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 followi ng diseases? （Each item must be an sweredYes or No ）斑疹伤 寒 Typh

2、us fever No Yes细菌性痢疾 Bacillary dysentery小儿麻痹症Poliomyelitis 白 喉 Diphtheria 猩红热 Scarlet fever No Yes回归热 Relapsing fever No Yes No Yes 布氏杆菌病 Brucellosis No Yes病毒性肝炎 Viral hepatitis No Yes产褥期链球菌 Puerperal streptococcus感染 infection No Yes No Yes NO Yes No Yes No Yes伤寒和副伤寒 Typhoid and paratyphoid fever流行性

3、脑脊髓膜炎Epidemic cerebrosp inal menin gitis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 followingdiseases or disordersendangering the public order and secure?（Each item must be answered“ Yes” or “ Nc” ）毒物瘾 Toxicomania 精神错乱 Mental confusion 精神病 Psychosis :躁狂型 Manic psychosis -妄想型 Paranoid

4、psychosis幻觉型 Halluci natory psychosis No YesNo NoNoNo No Yes Yes Yes Yes Yes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Visio n辨色力/Color sense耳 /Ears心 /Heart矫正视力Corrected visio n皮肤/Skin鼻/Nose肺 /Lungs眼 Eyes淋巴结 /Lymph nodes扁桃体/Tonsils腹部 /

5、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 Serodiag no sis)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 follow ingdiseases or disorders found duri ng the prese nt exam in ati on.霍乱 Cholera性病 Ven ereal 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