外国人体格检查表

1、外国人体格检查表FOREIGNER PHYSICAL EXAMINATION FORM姓名性别男 Male出生日期NameSex女 FemaleBirthday现在通讯地址Prese nt maili ng address出生地血型照片加盖检查单位印章国籍或地区Natio nality(or Area)BirthplaceBlood typePhoto(Stamped OfficialStamp)过去是否患有以下疾病：每项后面请答复“否或“是Have you ever had any of the follow ing diseases? (Each item must be an swere

2、dToxicoma niaNo YesMen tal con fusi onNo YesPsychosis：躁狂型Manic paychosisNo Yes妄想型Para noid psychosisNo Yes幻觉型Halluc in atoryNo Yes身高厘米体重公斤血压毫米汞柱HeightCMWeightKgBlood pressuremmHg发育情况Developme nt营养情况Nourishme nt颈部Neck视力左LVision右 R矫正视力左LCorrected vision 右 R_Eyes辨色力Colour sense皮肤Skin淋巴结Lymph no des班疹 伤

3、寒 Typhus fever No Yes小儿菌痢Bacillary dyse ntery No Yes麻痹症Poliomyelitis No Yes 白布氏杆菌病Brucellosis No Yes喉 Diphtheria No Yes 猩红病毒性肝炎Viral hepatitis No Yes热Scarlet fever No Yes 回归产褥期链球Puerperal streptococcus in fecti on热Relapsi ng fever No Yes菌感染 No Yes伤寒和付伤寒Typhoid and paratyphoid fever No Yes流行性脑脊髓膜炎Epi

4、demic cerebrosp inal menin gitis No Yes)是否患有以下危及公共秩序和平安的病症:Yes ora k | No每项后面请答复“否或“是Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be an swered“ Yes or“ No)毒物瘾精神错乱精神病扁桃体EarsNoseTon sils腹部HeartLungsAbdome n脊柱Spi ne四肢Extremities神经系统Ne

5、rvous system其他所见Other abno rmal 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ECC化验室检杳(包括 艾滋病、梅毒等血 清学检查)Laboratory exam (attached test report ofAIDS, Syphilis etc)未发现患有以下检疫传染病和危害公共健康的疾病：None of the follow ing diseases of disorders found duri ng the prese nt exam in atio n. 霍乱Cholera性病Ven ereal Disease黄热病Yellow fever肺结核Lu ng tuberculosis鼠疫Plague艾滋病AIDS麻风Lep