外国人体检表.pdf
外国人体检表
简介：本文档为《外国人体检表pdf》，可适用于其他资料领域
外国人体格检查表FOREIGNERPHYSICALEXAMINATIONFORM姓名Name性别Sex□男Male□女Female出生日期Birthday现在通讯地址Presentmailingaddress国籍或地区Nationality(orArea)出生地Birthplace血型Bloodtype照片(加盖检查单位印章)Photo(StampedOfficialStamp)过去是否患有下列疾病：（每项后面请回答“否”或“是”）Haveyoueverhadanyofthefollowingdiseases(Eachitemmustbeanswered“Yes”or“No”)班疹伤寒Typhusfever□No□Yes小儿麻痹症Poliomyelitis□No□Yes白喉Diphtheria□No□Yes猩红热Scarletfever□No□Yes回归热Relapsingfever□No□Yes菌痢Bacillarydysentery□No□Yes布氏杆菌病Brucellosis□No□Yes病毒性肝炎Viralhepatitis□No□Yes产褥期链球Puerperalstreptococcusinfection菌感染□No□Yes伤寒和付伤寒Typhoidandparatyphoidfever□No□Yes流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□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”)Doyouhaveanyofthefollowingdiseasesordisordersendangeringthepublicorderandsecurity(Eachitemmustbeanswered“Yes”or“No”)毒物瘾Toxicomania…………………………………………………□No□Yes精神错乱Mentalconfusion……………………………………………□No□Yes精神病Psychosis：躁狂型Manicpaychosis…………………………………□No□Yes妄想型Paranoidpsychosis………………………………□No□Yes幻觉型Hallucinatory……………………………………□No□Yes身高厘米HeightCM体重公斤WeightKg血压毫米汞柱BloodpressuremmHg发育情况Development营养情况Nourishment颈部Neck视力左LVision右R矫正视力左LCorrectedvision右R眼Eyes辨色力Coloursense皮肤Skin淋巴结Lymphnodes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Nervoussystem其他所见Otherabnormalfindings胸部X线检查结果(附检查报告单)ChestXrayexam(attachedchestXrayreport)心电图ECC化验室检查(包括艾滋病、梅毒等血清学检查)Laboratoryexam(attachedtestreportofAIDS,Syphilisetc)未发现患有下列检疫传染病和危害公共健康的疾病:Noneofthefollowingdiseasesofdisordersfoundduringthepresentexamination霍乱Cholera性病VenerealDisease黄热病Yellowfever肺结核Lungtuberculosis鼠疫Plague艾滋病AIDS麻风Leprosy精神病Psychosis意见检查单位盖章SuggestionOfficialStamp医师签字日期SignatureofphysicianDateFOREIGNERPHYSICALEXAMINATIONFORMName
