外国人体格检查记录
2012-12-26

 外国人体格检查记录

PHYSICAL EXAMINATION RECORD FOR FOREIGNER

姓 名

Name

 

 

性别□男Male

Sex □女Female

出生日期        

Birth Day

照片

photo

国籍

Nationality

 

出生地

Birth Place

 

血型

Blood Type

 

 

现在通讯地址

Present mailing address

 

 

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 answeredYesorNo)

斑 疹 伤 寒 Typhus fever No  Yes    细菌性痢疾 Bacillary dysentery        No  Yes

小儿麻痹症Poliomyelitis  No  Yes    布氏杆菌病Brucellosis                 No  Yes

     Diphtheria     No  Yes    病毒性肝炎Viral hepatitis             No  Yes

猩 红 热Scarlet fever    No  Yes    产褥期链球菌 Puerperal streptococcus  NO  Yes

回 归 热 Relapsing fever No  Yes    感 染infection                        No  Yes

伤寒和副伤寒 Typhoid and paratyphoid fever                                    No  Yes

流行性脑脊髓膜炎  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 must be answered YesorNo)

毒物瘾 Toxicomania………………………………………………………………………………□No  Yes

精神错乱Mental confusion …………………………………………………………………… □No  Yes

精神病Psychosis:躁狂型  Manic psychosis…………………………………………………□No  Yes

                  妄想型  Paranoid psychosis     ………………………………………□No  Yes

                幻觉型  Hallucinatory psychosis ……………………………………… □No  Yes

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

L

 

R

矫 正 视 力

Corrected vision

L

 

R

Eyes

辨 色 力/Color sense                                                  

皮肤/Skin                            

淋巴结/Lymph nodes

/Ears                                                            

/Nose                             

扁桃体/Tonsils

/Heart                                                           

/Lungs                             

腹部/Abdomen

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.

  Cholera

 

        Venereal Disease

 

黄热病 Yellow fever

 

开放性肺结核 Opening lung tuberculosis

 

  Plague

 

      AIDS

 

  Leprosy

 

      Psychosis

 

 

Suggestion

 

 

 

 

 

 

                        

                          检查单位盖章

                           Official Stam

 

   医师签字:                                         日期:

Signature of physician                                 Date

                       

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