外国人体格检查表.doc

《外国人体格检查表.doc》由会员分享，可在线阅读，更多相关《外国人体格检查表.doc（2页珍藏版）》请在得力文库 - 分享文档赚钱的网站上搜索。

1、外 国 人 体 格 检 查 表FOREIGNER PHYSICAL EXAMINATION FORM姓名Name性别Sex 男 Male 女 Female出生日期Birthday照片 (加盖检查单位印章)Photo(Stamped OfficialStamp)现在通讯地址Present mailing address国籍或地区 Nationality (or Area)出生地 Birth place血型Blood type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

2、must be answered “Yes” or “No”)班疹伤寒Typhus feverNo Yes菌痢Bacillary dysenteryNo Yes小儿麻痹症PoliomyelitisNo Yes布氏杆菌病BrucellosisNo Yes白喉DiphtheriaNo Yes病毒性肝炎Viral hepatitisNo Yes猩红热Scarlet feverNo Yes产褥期链球Puerperal streptococcus infection回归热Relapsing fever No Yes菌感染No Yes伤寒和付伤寒Typhoid and paratyphoid feverN

3、o Yes流行性脑脊髓膜炎Epidemic cerebrospinal meningitisNo 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 you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered “Yes” or “No”)毒物瘾 ToxicomaniaNo Yes精神错乱 Mental confusionNo Yes 精神病 Psychosis：躁狂型 Manic

4、paychosisNo Yes妄想型 Paranoid psychosisNo Yes幻觉型 HallucinatoryNo Yes身高厘米HeightCM体重公斤WeightKg血压毫米汞柱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 L Corrected vision 右 R 眼Eyes辨色力Colour sense皮肤Skin淋巴结Lymph nodes耳Ears鼻Nose扁桃体Tonsils心Heart肺Lungs腹部Abdomen脊柱Spine四肢Extremities神经系统Ne

5、rvous system其他所见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 ECC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)未发现患有下列检疫传染病和危害公共健康的疾病:None of the following diseases of 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 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 physicianDate