外国人体格检查记录

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1、外国人体格检查记录PHYSICALEXAMINATIONRECORDFORFOREIGNER姓名Name性别Sex□男□女出生日期BirthDay-Month-Year照片Photo现在通讯地址Presentmailingaddress血型Bloodtype国籍Nationality出生地址BirthPlace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”)　斑疹伤寒Typhusfever□No□Yes菌　　

2、　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病毒性性肝炎Viralhepatitis□No□Yes　猩红热Scarletfever□No□Yes产褥期链球菌Puerperalstreptococcusinfection感染□No□Yes　伤寒和付伤寒Typhoidandparatyphoidfever□No□Yes　流行性脑脊髓炎Epidemiccerebrospinalmeningitis□No□Yes　是否

3、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Manicpsychosis□No□Yes妄想型Paranoidpsychosis□No□Yes幻觉型Hallucinatorypsy

4、chosis□No□Yes身高Heightcm体重Weightkg血压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肤色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其它所见Otherabnormalfindings胸部Ｘ线检查ChestX-rayexa

5、m心电图ECG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　黄热病Yellowfever开放性肺结核Openinglungtuberculosis　鼠　疫Plague艾　滋　病AIDS　麻　风Leprosy精　神　病Psychosis　意见检查单位盖章　SuggestionOffi

6、cialStamp　　　　医师签字日期　SignatureofphysicianDate