居留或定居健康检查项目表

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1、醫院標誌Hospital’sLogo居留或定居健康檢查項目表HealthCertificateforResidenceApplication檢查日期/DateofExaminationYYYY/MM/DD(醫院名稱、地址、電話、傳真)(Hospital’sName,Address,Tel,Fax)基本資料/BasicData：姓名Name：□男/M□女/F性別Sex照片/Photo：身份證字號IDNo.：護照號碼PassportNo.：YYYY/MM/DD出生年月日DateofBirth：國籍Nat

2、ionality：年齡Age：聯絡電話PhoneNo.實驗室檢查/LaboratoryExaminationsA.胸部X光肺結核檢查/ChestX-rayforTuberculosis：X光發現/Findings：判定/Result：□合格/Passed□疑似肺結核/TBsuspect□無法確認診斷/Pending□不合格/Failed□孕婦或12歲以下兒童免驗/Notrequiredforpregnantwomenorchildrenunder12yearsofageB.腸內寄生蟲糞便檢查/Sto

3、olExaminationforParasites：□陽性，種名/Positive,Species□陰性/Negative□其他可不予治療之腸內寄生蟲/Otherparasitesthatdonotrequiretreatment□來自附錄三之國家/地區者免驗/Notrequiredforapplicantsfromcountries/areaslistedinAppendix3C.梅毒血清檢查/SerologicalTestsforSyphilis：檢驗/Tests：a.□RPR□VDRL□陽性/

4、Positive，效價/Titers□陰性/Negative，效價/Titersb.□TPHA□TPPA□FTA-abs□TPLA□EIA□CIA□陽性/Positive，效價/Titers□陰性/Negative，效價/Titersc.□other□陽性/Positive，效價/Titers□陰性/Negative，效價/Titers判定/Result：□合格/Passed□不合格/Failed□15歲以下兒童免驗/Notrequiredforchildrenunder15yearsofageD.

5、麻疹及德國麻疹之抗體陽性檢查報告或預防接種證明/ProofofPositiveMeaslesandRubellaAntibodyorMeaslesandRubellaVaccinationCertificates：a.抗體檢查/AntibodyTests麻疹抗體/MeaslesAntibody□陽性/Positive□陰性/Negative□未確定/Equivocal德國麻疹抗體/RubellaAntibody□陽性/Positive□陰性/Negative□未確定/Equivocalb.預防接種證

6、明/VaccinationCertificates(證明應包含接種日期、接種院所及疫苗批號；接種日期與出國日期應至少間隔兩週/Thecertificateshouldincludethedateofvaccination,thenameofadministeringhospitalorclinicandthebatchno.ofvaccine;thedateofvaccinationshouldbeatleasttwoweekspriortotravelingoverseas.)□麻疹預防接種證明/

7、MeaslesVaccinationCertificate□德國麻疹預防接種證明/RubellaVaccinationCertificatec.□有接種禁忌，暫不適宜預防接種/Havingcontraindications,notsuitableforvaccination漢生病檢查/ExaminationsforHansen’sDisease全身皮膚視診結果/SkinExamination□正常/Normal□異常/Abnormal：○非漢生病/NotrelatedtoHansen’sdiseas

8、e：○疑似漢生病須進一步檢查/Hansen’sdiseasesuspectwhoneedsfurtherexaminationsa.病理切片/SkinBiopsy：b.皮膚抹片/SkinSmear：○陽性/Positive○陰性/Negativec.皮膚病灶合併感覺喪失或神經腫大/Skinlesionscombinedwithsensorylossorenlargementofperipheralnerves：○有/Yes○無/No判定/Result：□合格/Pass