外国人体格检查表.docx

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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 m

2、ust be answered “Yes” or “No”)班 疹 伤 寒 Typhus fever No Yes 小儿麻痹症 Poliomyelitis No Yes 白 喉 Diphtheria No Yes 猩 红 热 Scarlet fever No Yes 回 归 热 Relapsing fever No Yes菌痢Bacillary dysenteryNo Yes布氏杆菌病BrucellosisNo Yes病毒性肝炎Viral hepatitisNo Yes产褥期链球Puerperal streptococcus infection菌感染No Yes伤寒和付伤寒Typhoid an

3、d paratyphoid feverNo 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 Psy

4、chosis： 躁狂型 Manic psychosisNo 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 L Vision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S

5、pine四肢Extremities神经系统Nervous 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ECG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