境外人员体格检查记录

1、境外人员体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER OR OVERSEAS CHINESE姓 名Name性别Sex男Male女Female出 生 日 期Birthday-Month-Year照 片 photo 现在通讯地址Present mailing address血 型Blood type国 籍Nationality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?(Each item must be answ

2、ered “Yes” or “No”)斑诊伤寒Typhus fever No Yes 菌 痢Bacillary dysenteryNoYes小儿麻痹症 PoliomyelitisNo Yes 布氏杆菌病 Brucellosis NoYes白 喉 Diphtheria No Yes 病毒性肝炎 Viral Hepatitis No Yes猩红热 Scarlet fever No Yes 产褥期链球菌Puerperal Streptococcus Infection NoYes回归热 Relapsing fever No Yes 感染 Infection NoYes伤寒和付伤寒 Typhoid a

3、nd paratyphoid fever No Yes流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis No 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 yo have any of the following diseases or disorders endangering the public order security? (Each item must be answered “Yes” or “No”)毒物瘾 Toxicomania No Yes精神错乱Mental confusionNo Yes精神病Psy

4、chosis：躁狂型Manic psychosis. No Yes 妄想型Paranoid psychosis . No Yes 幻觉型Hallucinatory psychosis. No Yes身高Height cm 体重Weight Kg血压Blood pressure mmHg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辩色力Colour sense 皮肤Skin淋巴结Lymph Nodes耳Ears 鼻Nose扁桃体Tonsils心Heart 肺Lungs 腹

5、部Abdomen脊柱Spine 四肢Extremities神经系统Nervous system其它所见Other abnormal findings胸部X线检查Chest X-rayExam心 电 图ECG化验室检查（包括爱滋病、梅毒等血清诊断）LaboratoryExam.(AIDS. Syphilis etc. Serodiagnosis)未发现患有下列建议传染病和危害公共健康的疾病:None of the following diseases or disorders found during the president examination霍乱 Cholera 性病Venereal Disease黄热病Yellow fever 开放性肺结核Opening Lung Tuberculosis鼠疫 Plague 爱滋病AIDS麻风