外国 人 体 格 检 查 表 - 武汉工程大学外事处国际学院

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 EXAMINA TION RECORD FOR FOREIGNER姓名Name 性别Sex男□Male女□Female出生日期Birth day现在通讯地址present mailing address国籍Nationality出生地址Birth place血型Bloodtype照片Photo过去是否患有以下疾病：（每项后面请回答“是”或“否”）Have you ever had any of rhe following diseases?斑疹伤寒Typhus fever □No □Yes 菌痢Bacillarydysentery □No □Yes 小儿麻痹Poliomyelitis □No □Yes 布氏杆菌Brucellosis □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 & 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“是”或“否”）Do you have any of the following diseases or disorders endangering the public order and security?毒物瘾Toxicomamia □No □Yes精神错乱Mental confusion □No □Yes精神病Psychosis 狂躁症Manic psychosis □No □Yes妄想症Paranoid psychosis □No □Yes幻想症Hallucinatory psychosis □No □Yes身高Height cm 体重Weight Kg血压Blood Pressure mmHg发育状况Development 营养情况Nourishment颈部Neck视力左L Vision 右R 矫正视力左LCorrected vision 右R眼Eyes辩色力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 * Please turn over the form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化验室检查包括血清学诊断Laboratory exam(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 性病venereal disease黄热病Yellowfever 开放性肺结核Openning lung Tuberculosis 鼠疫Plague 爱滋病AIDS麻风leprosy 精神病Psychosis意见Suggestionj检查单位盖章Official Stamp医师意见Signature of physician 日期DateEnd of the form。