外国人体格检查记录 - study in china study in

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1、外国人体格检查记录PhysicalExaminationRecordForForeigners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”）Haveyoueverhadanyofthefollowingdiseases？（Eachitemmustbeanswered“Yes”or“No”）班疹伤寒Typhus

2、fever□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Scarletferver□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Epidemi

3、ccerebrospinalmeningitis□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..................................................................................

4、□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Hallucinatorypsychosis…………………...□No□Yes身高Heightcm体重Weightkg血压Bloodpressure发育情况Development营养情况Nouris

5、hment颈部Neek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Tonsil心Hear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Laboratoryexam(Serodiagnosis)未发现患有下列检疫传染病和危害公共健康的疾病：None

6、ofthefollowingdiseasesordisordersfoundduringthepresentexamination霍乱Cholera性病VenerealDisease黄热病Yellowfever开放性肺结核Openinglungtuberculosis鼠疫Plague艾兹病AIDS麻风Leprosy精神病Psychosis意见检查单位盖章SuggestionOfficialStamp医师签字日期SignatureofphysicianDate