申请号(办公室填写)

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1、外国人体格检查表FOREIGNERPHYSICALEXAMINATIONFORM姓名Name性别Sex□男Male□女Female出生日期BirthDay–Month-Year照片(加盖检查单位印章)Photo(stampedOfficialstamp)现在通信地址Presentmailingaddress血型Bloodtype国籍或地区Nationality(orArea)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”）Haveyoueverhadanyofthefollowingdeseases?(Each

2、itemmustbeanswered“Yes”or“No”)斑疹伤寒Typhusfever□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Puerperalstreptococcusinfection回归热Relapsingfever□No□Yes菌感染□No□Yes伤寒和付伤寒Typho

3、idandparatyphoidfever□No□Yes流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□No□Yes是否患有下列危机公共秩序和安全的病症：（每项后面请回答“否”或“是”）Doyouhaveanyofthefollowingdiseasesordisordersendangeringthepublicorderandsecurity?(Eachitemmustbeanswered“Yes”of“No”)毒物瘾Toxicomania………………………………………………………………………□No□Yes精

4、神错乱Mentalconfusion………………………………………………………………□No□Yes精神病Psychosis：躁狂型ManicPaychosis………………………………………□No□Yes妄想型Paranoidpsychosis………………………………………□No□Yes幻想型Hallucinatorypsychosis……………………………………□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

5、L________Vision右R矫正视力左L_______Correctedvision右R眼Eyes辨色力Coloursenses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其它所见Otherabnormalfindings胸部X线检查结果（附检查报告单）ChestX-rayExam(attachedchestX-rayreport)心电图ECG化验室检查（包括艾滋病、梅毒等血清学检查）Lab

6、oratoryexam(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S

7、ignatureofphysicianDateTheforeignersaresupposedtotakethephysicalexaminationbeforeleavinginanationalorregionalpublichospitalandgetreportofalltheitemslistedintheformwiththesignatureofthedoctorandthestampofthehospital.Ifthecheckisdoneinaprivatehospitalorclinic,thereportshouldbe

8、notarizedbyapublicnotary.Theformsubmittedshouldbetheoriginalcopywiththephot