境外人员体格检查记录

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1、境外人员体格检查记录PHYSICALEXAMINATIONRECORDFORFOREIGNER姓名性别□男Male出生日期NameSex□女FemaleDateofBirthDay/Month/Year照片现在通讯地址血型PresentaddressBloodPhototype国籍出生地址NationalityBirthPlace过去是否患有下列疾病：(每项后面请回答“是”或“否”)Haveyoueverhadanyofthefollowingdiseases?(Eachitemmustbeanswered“Yes”or“No”)斑疹伤寒Typhusfever

2、□No□Yes菌痢Bacillarydysentery□No□Yes小儿麻痹症Poliomyelitis□No□Yes布氏杆菌病Brucellosis□No□Yes白喉Diphtheria□No□Yes病毒性肝炎Viralhepatitis□No□Yes猩红热Scarletfever□No□Yes产褥期链球菌Puerperalstreptococcusinfection回归热Relapsingfever□No□Yes感染□No□Yes伤寒和付伤寒Typhoidandparatyphoidfever□No□Yes流行性脑脊髓膜炎Epidemiccerebrosp

3、inalmeningitis□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”)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Manic

4、psychosis………………………………□No□Yes妄想型Paranoidpsychosis…………………………□No□Yes幻觉型Hallucinatorypsychosis……………………□No□Yes身高厘米体重公斤血压毫米汞柱HeightcmWeightkgBloodpressuremmHg发育情况营养情况颈部DevelopmentNourishmentNeck视力左L矫正视力左L眼Vision右RCorrectedVision右REyes辨色力皮肤淋巴结ColoursenseSkinLymphnodes耳鼻扁桃体EarsNoseTonsils心肺

5、腹部HeartLungsAbdomen编号：42（19X27cm）1脊柱四肢神经系统SpineExtremitiesNervoussystem其他所见Otherabnormalfindings肺部X线心电图检查ChestX-rayECGExam.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：Noneofthefollowingdiseasesordisordersfoundduringthepresentexamination霍乱Cholera性病VenerealDisease

6、黄热病Yellowfever开放性肺结核Openinglungtuberculosis鼠疫Plagus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SignatureofphysicianDate2