外国人体格检查表

外国人体格检查记录Physical Examination Record for Foreigner姓名性别□男Male 出生日期Name Sex □女Female Birth Day-Month-Year照现在通讯地址血型Present Mailing Address Blood 片国籍出生地址typePhotoPlaceNationality Birth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 Typhus fever □No □Yes 菌痢Bacillary dysentery □No □Yes小儿麻痹症 Pollomyclitis □No □Yes 布氏杆菌病Bruccllosis □No □Yes白喉 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 infection回归热 Relapsing fever □No □Yes 感染□No □Yes伤寒和付伤寒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身高体重血压Height cm Weight kg Blood pressure mmHg发育情况营养情况颈部Development Nourishment Neck视力左L 矫正视力左L 眼右R EyesVision 右R Correctedvision辨色力皮肤淋巴结Colour Sense skin Lymph nodes耳鼻扁桃体Ears Nose Tonsils心肺腹部Heart Lungs Abdomen脊柱四肢神经系统system Spine Extremities Nervous其它所见Other abnormal finding胸部X线心电图检查Chest X-ray E C Gexam.化验室检查包括血清学诊断Laboratoryexam.(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.Disease性病 Venereal 霍乱 Cholerafever开放性肺结核Opening lung tuberculosis 黄热病 Yellow艾滋病 AIDS 鼠疫 Plague精神病 Psychosis 麻风 Leprosy意见检查单位盖章StampOfficial Suggestion医师签字日期DatePhysicianofSignature。

外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓名 Name性别□男Male Sex □女 Female 岀生日期 年 月 日Date of Birth y. m. d. 现在通迅地址 Prese nt maili ng adderss 血型 Blood Type国籍 Nation ality出生地 Birth Place （Put ospital seal across the photo ）照片 Photo 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 followi ng diseases?（Each ietm must be an swered Yes"or No"No Yes No | — Yes 斑疹伤寒 Typhus fever —N O — Yes 细菌性痢疾 Bacillary dysentery 小儿麻痹症 Poliomyelitis '— N O | Yes 布氏杆菌病 Brucellosis 匚 No 二 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 — N O [_ Yes 回归热Relapsing fever | NO Yes 感 染『fection _J No — Yes Diphtheri a 伤寒和副伤寒 Typhoid and paratyphoid fever_ No | Yes 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 follow ing diseases or disorders endan geri ng the public order and secure? （Each item most be answered Yes" or No ”）毒物瘾 Toxicomani a …精神错乱 Me ntal co nfusi on 精神病Psychosis ：躁狂型 妄想型幻觉型 流行性脑脊髓膜炎 Epidemic cerebrosp inal menin gitisManic psychosis …• Paranoid psychosis • Halluc in atorypsychosis □ No □Yes □ No □ Yes □ No □ Yes □ No □ Yes □ 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 Developme nt营养情况 Nourishme nt 颈部Neck视力 Visio n 辨色力 /Color sense 矫正视力 Corrected visio n 皮肤/Skin耳 /Ears 鼻 /Nose 心 /Heart肺/Lungs 眼 Eyes淋巴结 /Lymph nodes扁桃体/Tonsils腹部 /Abdomen（注：表格素材和资料部分来自网络，供参考。