外国人体格检查记录.doc

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1、外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓 名Name性别 男MaleSex 女Female出 生 月 年Birth Day Month Year照片photo现在通讯地址Present mailing address血型Blood Type国籍Nationality出生地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 answered“Yes”or“No”)斑 疹 伤 寒

2、 Typhus fever NoYes 细菌性痢疾 Bacillary dysentery NoYes小儿麻痹症Poliomyelitis NoYes 布氏杆菌病Brucellosis NoYes白 喉 Diphtheria NoYes 病毒性肝炎Viral hepatitis NoYes猩 红 热Scarlet fever NoYes 产褥期链球菌 Puerperal streptococcus NOYes回 归 热 Relapsing fever NoYes 感 染infection NoYes伤寒和副伤寒 Typhoid and paratyphoid fever NoYes流行性脑脊髓

3、膜炎 Epidemic cerebrospinal meningitis NoYes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 secure?(Each item most be answered “Yes”or“No”)毒物瘾 ToxicomaniaNoYes精神错乱Mental confusion NoYes精神病Psychosis：躁狂型 Manic psychosisNoYes 妄想型

4、 Paranoid psychosisNoYes 幻觉型 Hallucinatory psychosisNoYes身 高/Height (厘米/ cm)体 重/ Weight (公斤/ kg)血压/pressure Blood(毫米汞柱/mmHg)发育情况Development 营养情况Nourishment 颈部Neck视 力Vision左L右R矫 正 视 力Corrected vision 左 L右R眼Eyes辨 色 力/Color sense 皮肤/Skin 淋巴结/Lymph nodes耳/Ears 鼻/Nose 扁桃体/Tonsils心/Heart 肺 /Lungs 腹部/Abdom

5、en编号：42 （1927cm）脊柱/Spine 四肢/Extremities神经系统/Nervous system其他所见/Other abnormal findings胸部X线检查/Chest X-ray exam心电图/ECG化验室检查(包括艾滋病、梅毒血清学诊断)/Laboratory Exam (HIV, Syphilis Serodiagnosis)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

6、病 Venereal Disease黄热病 Yellow fever 开放性肺结核Opening lung tuberculosis鼠 疫 Plague 艾 滋 病 AIDS麻 风 Leprosy 精 神 病 Psychosis意 见Suggestion 检查单位盖章 Official Stamp 医师签字 日期Signature of physician Date编号：42 （1927cm）体 检 说 明EXPLANATION OF THE PHYSICAL EXAMINATION1在华学习六个月以上的外国留学生，应按照“外国人体格检查记录”进行体格检查。体检表贴照片处，应有医院印章，否则，

7、视体检表无效。The foreign students, who intend to study in China for 6 months of more, should go through a physical check-up before they come to China, according to the requirements of Physical Examination Record for Foreigners. The hospital seal should be put across the photo on the Examination Record, or

8、 the Record is invalid.2体检表应填写清楚，体检报告应附有X光透视胸片及霍乱、黄热、鼠疫、麻风、性病、开放性肺结核、艾滋病、肝功能、澳抗和精神病的化验室检查报告。外国留学生到天津大学报到时，我们将体检表及化验室检查报告送至天津市卫生检疫局查验。凡体检查验不合格者，需在天津市卫生检疫局重新检体，费用自理。All the items of this form should be filled in carefully and clearly. The report should be attached with the negative film for Chest X-ra

9、y exams, and the examination certificates for laborstory exams (Serodiagnosis), which include exams on Cholera, Yellow fever, Plague, Leprosy, Venereal Disease, Opening lung tuberculosis, AIDS, Psychosis, Liver function and HB&AG. On their arrival at University, the Record (a original copy) and labo

10、ratory exam certificates should be sent to Tianjin Quarantine Bureau for check. Those whose exam is not qualified should get the physical re-check up done in Tianjin. The expenses should be covered by themselves.3.体检应在来华一个月前在公立医院进行，凡在私立医院体检者，应取得公证部门的公证。到天津大学报到时，体检时间不得超过六个月，否则应在天津重新检体，费用自理。The physic

11、al examination should be taken in the public hospitals one month before their departure, If the physical check-up is done at a private hospital, the student should get the certificate notarized. If the physical check-up is over 6 months old on the day of their registration, they should have re-check

12、 up in Tianjin. The expenses should be covered by themselves.4.体检表是办理入境签证及在华居留手续所需文件之一，留学生到天津大学报到时，应提交正本。The Physical Examination Form is one of the documents that is needed in the process of going through the visa formalities. The students should bring the original copy along with them when they come to China.