出入境人员健康检查申请表

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. 出入境人员健康检查申请表 HEALTH EXAMINATION REGISTRATION FROM FOR THE PERSONS OF ENTRY-EXIT

姓名Name 职业 Occupation

已婚 Married □是Yes □否No 文化程度 Education

电话 Tel No. 前往国家 Destination

现单位Present Working Company

现地址Present Address

病史问卷 Medical History Questionaire(在医生指导下完成answer the following questions in the presence of the doctor)

过去是否患有下列疾病或危及公共秩序和安全的病症：如有请在下列相应疾病栏回答有，并详细说明。 Have you ever had any of the

following diseases or disorders endangering the public order and security? If you have or ever had ,Please answer Yes in the relative disease

and specify.

斑 疹 伤 寒 Typhoid fever □有 Yes 菌痢 Bacillary dysentery □有 Yes 小儿麻痹症 Poliomyelitis □有 Yes

布氏杆菌病 Brucellosis □有 Yes 白喉 Diphtheria □有 Yes 病毒性肝炎 Virus hepatitis □有 Yes

猩红热 Scarlet fever □有 Yes 回归热 Relapsing fever □有Yes 精神错乱 Mental confusion □有 Yes

精神病： 躁狂型 Manic

Psychosis： 妄想型 Paranoid

幻觉型 Hallucinatory □有 Yes 毒物瘾 Toxicomania □有 Yes 艾滋病 AIDS □有 Yes

□有 Yes 伤寒和副伤寒Typhoid

and paratyphoid fever □有 Yes 性病 Venereal Disease □有 Yes

□有 Yes 疟疾 Malaria □有 Yes 结核 Tuberculosis □有 Yes

产褥期链球菌感染（已生育女性填写） Puerperal streptococcus infection（For the bore women） □有 Yes 流行性脑脊髓膜炎Epidemic cerebrospinal

meningitis □有 Yes 其他传染病 Other

infections disease □有 Yes

最近7天内您是否有发热和咳嗽？□有 Have you had a fever or cough within the last 7days? □Yes

是否现患或曾患有其他疾病史？ □有 Have or had you ever had any other diseases？ □Yes

如果没有患有上述疾病或症状，请回答：□没有

If never have or had any diseases or symptoms which mentioned above , please answer：□No

如果曾/现患有上述疾病或症状，请详细说明：If have or had any diseases or symptoms which mentioned above , please specify:

签证必须检查项目(Required Tests for visa):

身高、体重、血压、体温、内外科、五官科、心电图、B超（肝胆脾、双肾）、X光胸片、血液检测（血型、谷丙转氨酶、乙肝表面抗原、艾滋病抗体、梅毒抗体、丙肝抗体），尿分析、血常规等 。 Height, Weight, Blood Pressure, Temperature, Internal Medicine, ENT,

EKG,B-ultrasound,(liver, gallbladder, spleen and kidneys), Chest X-ray, Blood Test(Blood Type, ALT, HBsAg， HIV, TPPA（or TRUST）,

Anti-HCV), Urinalysis and Blood Routine，etc。

本人申明以上提供的资料真实，已核对个人资料无误，并已知道体检内容，同意进行体检。

I declare that the information I have provided above is true to the best of my knowledge and I have checked that my personal information is correct

and I understand what is to be done during the examination and agree to have the examination which is mentioned above.

签名Signature:

推荐检查项目(Recommended Tests):

□乙肝四项（乙肝表面抗体、乙肝e抗原、乙肝e抗体、乙肝核心抗体）□ 甲肝抗体二项。□生化12项（肝功能：谷草转氨酶、谷氨酰转肽酶、总蛋白、白蛋白、球蛋白、白/球。血脂：总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇。肾功能：血尿素氮、血肌酐。其它：血尿酸、血糖），□甲胎蛋白(肝癌检查) 癌胚抗原（肠癌检查）□EB病毒（鼻咽癌筛查）。 □B超检查:男性前列腺。

□骨密度检测。 □粪便培养。 □粪便常规。□乙肝表面抗体（定量、定性）。□乙肝病毒基因检测。□PPD试验。

□ Test for Hepatitis B( HBsAb,HBeAg,HBeAb,HBcAb).□ HBsAb（Quantitative、Qualitative）□Test for Hepatitis A(HAV-IgM,HAV-IgG).

□Biochemical test: （Test for Liver function: AST, r-PT, T.Prot ，ALB, GLOB, A/G. Test for Blood-Lipid: CHOL,TG,HDL-C,LDL-C. Test for

Kidney function: BUN, Creatinine. Other: UA, GLU. ）. □AFP（Test for Hepatic carcinoma）.CEA(Test for Intestinal Carcinoma) □VCA-IgA（Screening test for Nasopharyngeal Carcinoma）.□B-ultrasonic examination for Prostate(Male).□Examination for a bone

densitometry. □Feces culture.□Feces Routine. □ HBsAb（Quantitative、Qualitative）. □HBV-DNA.□PPD test.

□其他：Other:

□ 妇科: □B超检查子宫及附件。 □.电脑乳腺红外线检查。□ 妇女内外生殖器官检查+电脑辅助细胞学筛查(宫颈癌检查)。

Gynecological examination: □B-ultrasonic examination for Womb and Appendage.□Computer Diaphanography Imaging .□Edeoscopy and

Secretion routine ,Cervical exfoliative cytoliative examination by computer assistant (Examination for Cervical carcinoma.)

我已知道推荐的体检内容，同意进行上述检查。 I understand what is recommended and agree to get the examination which is mentioned above.

签名:signature:

□外文翻译 份 □X光报告、携带X光片 □HIV报告 □签发其它检查检验报告 □验证 □验血 □B超检查（肝、胆、脾、双肾）

备注：

审核医生签名： 日期: 年 月 日. date：