外国人体格检查记录-studymbbsinchina-china

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1、外国人体格检查记录PHYSICALEXAMINATIONRECORDFORFOREIGNERPleaseprintonbothsidesofasheetofpaper(duplex)姓名Name性别Sex□男Male□女Female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”）Haveyoueverhadanyofthefollowingdisea

2、ses?（Eachitemmustbeanswered“Yes”or“No”）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产褥期链球菌Puerperalstreptococcusinfection回归热Relapsingfever□No□Yes感染□No□Yes伤寒和

3、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”）Doyouhaveanyofthefollowingordisordersendangeringthepubicorderandsecurity?(Eachitemmustbeanswered“Yes”or“No”)毒物瘾Toxicmania……………………………………………………………………□No□Yes精神错

4、乱Mentalconfusion…………………………………………………………………□No□Yes精神病Psychosis:躁狂型ManicPsychosis……………………………………………□No□Yes妄想型ParanoidPsychosis…………………………………………□No□Yes纪觉型HallucinatoryPsychosis……………………………………□No□Yes身高Height体重Weight血压BloodpressuremmHg发育情况Development营养情况Nourishment颈部Neck视力左LVision右R

5、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其它所见Otherabnormalfindings胸部X线检查ChestX-rayExam心电图ECG化验室检查包括血清学诊断LaboratoryExamSerodiagnosis未发现患有下列检疫传染病和危害公共健康的疾病：Noneofthefollowingdise

6、asesordisordersfoundduringthepresentexamination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SuggestionOfficialStamp医师签字日期SignatureofphysicianDate