外国人体格检查表

1、外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓名性别男 Male出生日期 照 片NameSex女 FemaleBirth Day-Month-Year（加盖检查现在通讯地址单位印章）Present mailing address血型BloodPhoto国籍出生地址type(stampedNationalityOffical Stamp)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

2、 be answeredor“ yesNo“”斑疹伤寒Typhus feverNoYes菌痢Bacillary dysenteryNo Yes小儿麻痹症PoliomyelitisNoYes布氏杜菌病BrucellosisNo Yes白喉Diphtheria NoYes病毒性肝炎Viral hepatitisNo Yes猩红热Scarlet fever No Yes产褥期链球Puerperal streptococcus infection回归热Relapsing feverNo Yes菌感 染 No Yes伤寒和付伤寒Typhoid and paratyphoid feverNo Yes流行性

3、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疾病：（每项后面请回答“否”或“是” ）Do you have any of the following diseases or disorders endangering the pubic order and security?(Each item must be answered“ Yes” or “ No”)毒 物 瘾Toxicomania No Yes神经错乱Mental confusion No Yes神 经 病Psychosis: 躁狂型 Manic psyc

4、hosisNo Yes妄想型 Paranoid psychosisNo Yes幻想型 Hallucinatory psychosis No Yes身高厘米体重公斤血压千帕HeightcmWeightkgBlood pressureKPa发育情况营养情况颈部DevelopmentNourishmentNeck视力左 L矫正视力左 L眼Vision右 RCorrected vision右 REyes辨色力皮肤淋巴结Colour senseSkinLymph nodes耳鼻扁桃体EarsNoseTonsils心肺腹部HeartLungsAbdomen脊 柱四 肢神经系统SpineExtremitie

5、sNervous 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心电图ExamECG(Attachedchest X-rayreport(1)化验室检查抗 HIV (ELISA)(2)（包括 HIV 抗体、(3)梅毒等血清学检查, 并附原始检梅毒血清凝集反应查报告单）Syphilis serum agglutination reactionLaboratory exam(Attached testreport of AIDS,Syphilis etc)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Cholera性 病Venereal Disease黄热病Yellow fever肺结核lung tuberculosis鼠疫Plague艾滋病AID