附录2：《外国人体格检查记录》表

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1、附录2：《外国人体格检查记录》表外国人体格检査记录PHYSICALEXAMINATIONRECORDFORFOREIGNER姓名Name性别□男MaleSex□女Female出生年月BirthDayMonthYear照片photo国籍Nationality出生地BirthPlace血型BloodType现在通讯地址Presentmai1ingaddress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Typhus

2、feverDNoDYes细菌性痢疾Baci11arydysenteryDNoDYes小儿麻痹症PoliomyelitisDNoDYes布氏杆菌病BrucellosisDNoDYes白喉DiphtheriaDNoDYes病毒性肝炎ViralhepatitisDNoDYes猩红热ScarletfeverDNoDYes产褥期链球菌PuerperalstreptococcusDNODYes回归热RelapsingfeverDNoDYes感染infectionDNoDYes伤寒和副伤寒TyphoidandparatyphoidfeverCNoDYes流行性脑脊髓膜炎Epidemicce

3、rebrospinalmeningitisDNoDYes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”）（Eachitemmustbeanswered“Yes”or"No"）毒物瘾ToxicomaniaDNoDYes精神错舌LMentalconfusionDNoDYes精神病Psychosis：躁狂型ManicpsychosisDNoUYes妄想型ParanoidpsychosisDNoDYes幻觉型HallucinalorypsychosisDNoDYcsDoyouhaveanyofthefollowingdiseasesordisordersend

4、angeringthepublicorderandsecure?身高/Height（厘米/cm）体重/Weight（公斤/kg）血压/pressureBlood（毫米汞柱/mmHg）发育情况Developmcnt营养情况Nourishment颈部Neck视力左L矫正视力左L眼EyesVision右RCorrectedvision右R辨色力/Colorsense皮肤/Skin淋巴结/Lymphnodes耳/Ears鼻/Nose扁桃体/Tonsils妄想型ParanoidpsychosisDNoDYes幻觉型HallucinalorypsychosisDNoDYes心/Heart

5、肺/Lungs腹部/Abdomen脊柱/Spine四肢/Extremities神经系统/Nervoussystem其他所见/Otherabnormalfindings胸部X线检査/ChestX-rayexam心电图/ECG化验室检查(包括艾滋病、梅毒血清学诊断)/LaboratoryExam(HIV,SyphilisSerodiagnosis)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VenerealDiseas

6、e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Suggestion检查单位盖章OfficialStam医师签字：口期：Signatureofphysician：Date：外国人体格检查记录PHYSICALEXAMINATIONRECORDFORFOREIGNER体检说明EXPLANATIONOFTHEPHYSICALEXAMINATION1.在华学习六个月以上的外国射学生，应按照“外国人体格检查记录”进行体格检杳。体检表贴照片处，应有医院印章，否则，视体检表无

7、效。I・Theforeignstudents,whointendtostudyinChinafor6monthsormore,shouldgothroughaphysica1check-upbeforetheycometoChina,accordingtoIherequirementsofPhysicalExaminationRecordforForeigners.Thehospitaisealshou]dbeputacrossthephotoontheExaminationRecord,ortheRe