PHYSICAL EXAMINATION RECORD FOR FOREIGNER

现在通讯地址

Present mailing address

血型

Blood

type

国籍

Nationality

出生地址

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Typhus fever□No□Yes菌痢Bacillary dysentery□No□Yes

小儿麻痹症Poliomyelitis□No□Yes布氏杜菌病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Puerperal streptococcus infection

回归热Relapsing fever□No□Yes菌感染□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共秩序和安全的疾病：（每项后面请回答“否”或“是”）

Do you have any of the following diseases or disorders endangering the pubic order and security?

(Each item must be answered “Yes” or “No”)

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

神经错乱Mental confusion…………………………………………………………………………□No□Yes

神经病Psychosis:躁狂型Manic psychosis……………………………………………………□No□Yes

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

幻想型Hallucinatory psychosis……………………………………………□No□Yes

身高厘米

Heightcm

体重公斤

Weightkg

血压千帕

Blood pressureKPa

发育情况

Development

营养情况

Nourishment

颈部

Neck

视力左L

Vision右R

矫正视力左L

Corrected vision右R

眼

Eyes

辨色力

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

脊柱

Spine

四肢

Extremities

神经系统

Nervous system

其它所见

Other abnormal findings

胸部X线

检查结果

（附检查报告单）

Chest X-ray

Exam

(Attached

chest X-ray

report

心电图

ECG

化验室检查

（包括艾滋病、梅毒等血清学检查）

Laboratoryexam

(Attached test report of AIDS, Syphilis etc)

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Yellow fever肺结核lung tuberculosis

鼠疫Plague艾滋病AIDS

麻风Leprosy精神病Psychosis

意见检查单位盖章

SuggestionOfficial Stamp

医师签字日期

Signature of physicianDate