外国学生体检表

外国学生体检表外国学生体检表外国学生体格检查表 PHYSICAL EXAMINATION RECORD FOR FOREIGNER 姓性别 ? 男Male 出生日期Surname 照片必须加盖医名 Sex ? 女FemaleBirthday First name 院公章现在通讯地址血型 Photo must be Present mailing address Blood type stamped by 国籍出生地址 hospital seal Nationality Birth Place 过...

外国学生体检表外国学生体格检查表 PHYSICAL EXAMINATION RECORD FOR FOREIGNER 姓性别 ? 男Male 出生日期Surname 照片必须加盖医名 Sex ? 女FemaleBirthday First name 院公章现在通讯地址血型 Photo must be Present mailing address Blood type stamped by 国籍出生地址 hospital seal Nationality Birth Place 过去是否患有下列疾病(每项后面请回答“是”或“否”表示) 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痢疾 Bacillary dysentery ?No ?Yes 小儿麻痹症Poliomyelitis?No ?Yes ?No ?Yes 布氏杆菌症Brucellosis白喉Diphtheria ?No ?Yes 病毒性肝炎Viral hepatitis ?No ?Yes 猩红热Scarlet fever ?No ?Yes 回归热Relapsing fever ?No ?Yes 产褥期链球菌感染Puerperal streptococcus infection ?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病症(每项后面请回答“是”或“否”表示) 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 ?No ?Yes 妄想型 Paranoid psychosis „„„„„„„„„„„„ 幻觉型 Hallucinatory psychosis „„„„„„„„„„ ?No ?Yes 身高厘米体重公斤血压毫米汞柱 Height cm Weight KgBlood pressure mmHg 发育情况营养状况颈部 Development Nourishment Neck 左L 左L 视力矫正视力眼 Vision Corrected vision Eyes 右R 右R 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 1 脊柱四肢神经系统 Spine Extremities Nervous system 其他所见 Other abnormal findings 胸部X线检查结果心电图 Chest X-ray ECG Exam 艾滋病病毒抗体/Anti-HIV 梅毒初筛试验/Syphilis(screen) 梅毒确诊试验/Syphilis(confirmation) 化验室检查乙型肝炎表面抗原/HBsAg Laboratory test 丙型肝炎抗体/Anti-HCV 丙氨酸氨基转移酶/ALT(GPT) 总胆红素(酶法)/TBIL 天冬氨基酸转移酶/AST(GOT) 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 has found during the present examination 霍乱 Cholera 性病 Venereal diseases 黄热病 Yellow fever 开放性肺结核 Opening lung tuberculosis 鼠疫 Plague 艾滋病 AIDS 麻风 Leprosy (或HIV感染)(or HIV infected) 精神病 Psychosis 意见检查单位盖章 Suggestion Official stamp 日期医师签字 Date Signature of physician 2 3

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外国学生体检表

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