1-3健康检查项目表(乙表)原表

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1、醫院標誌Hospital'sLogo檢查日期—//_(年)(月)(日)—/_/—(M)(D)(Y)DateofExamination健康檢査證明應檢查項目表(乙表)(醫院名稱、地址、電話、傳真機)ITEMSREQUIREDFORHEALTHCERTMCATE(FormB)(HospitafsName,Address,Tel,FAX)姓名：Name曉孚：□男Male□女Female昭片身份證字號護照號碼八、、丿1IDNo.Passport•PhotoNo.出生年月日.,/國籍DateofBirthe''Nationalitye年齡聯絡電話・AgePhoneNo.基本資料(

2、BASICDATA)驗室檢查(LABORATORYEXAMINATIONS)A.HIV抗體檢査(SerologicalTestforHIVAntibody):□陽性(Positive)□陰性(Negative)□未確定(Indeterminate)a•篩檢(ScreeningTest):DEIADPA口其他(Others)b•確認(ConfirmatoryTest):□WesternBlot□其他(Others)□兒童15歲以下免驗(Notrequiredforchildrenunder15yearsofage)B.胸部X光檢查肺結核(ChestX-RayforTube

3、rculosis):X光發現(Findings)：判定(Results)-□合格(Passed)□疑似肺結核(TBSuspect)□無法確認診斷(Pending)二不合格(Failed)(經臺灣健檢醫院判定爲疑似肺結核或無法確認診斷者，得至指定機構複驗；但所在縣市無指定機構者，得至鄰近醫院之胸腔科門診複檢0)(ThosewhoarcdeterminedtobeTBsuspectsorhaveapendingdiagnosisbythedesignatedhospitalinTaiwanmustvisitthereferredinstitutionforfurtherev

4、aluation.)］孕婦或兒童12歲以下免驗(Notrequiredforpregnantwomenorchildrenunder12yearsofage)C・腸內寄生,(含痢疾阿米巴等原蟲漢便檢査(採用離匚、濃縮法檢査XStoolexaminationforparasitesincludesEntamebahistolyticaetc.)(centrifugalconcentrationmethod):□陽性，種名(Positive,Species)ZJ陰性(Negative)□其他可不予治療之腸內寄生蟲(Otherparasitesthatdonotrequire

5、treatment)□兒童6歲以下或來自特定地區者免驗(Notrequiredforchildrenunder6yearsofageorapplicantsfromdesignatedareasasdescribedinNote6)D・梅毒血清檢查(SerologicalTestforSyphilis):檢驗(Tests):aORPR或□VDRLb.□TPHA/TPPAc，□其它(Other)判定(Results):□合格(Passed)□不合格(Failed)□兒童15歲以下免驗(Notrequiredforchildrenunder15yearsofage)E・麻疹

6、及德國麻疹之抗體陽性檢驗報告或預防接種證明(proofofpositivemeaslesandrubellaantibodytitersormeaslesandrubellavaccinationcertificates):a.抗體檢査(Antibodytest)麻疹抗體measlesantibodytiters□陽性Positive□陰性Negative□未確定(Equivocal)德國麻疹抗體rubellaantibodytiters□陽性Positive□陰性Negative□未確定(Equivocal)b・預防接種證明VaccinationCertificate

7、s(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相隔兩週。)(TheCertificateshouldincludethedateofvaccination,thenameofadministeringhospitalorclinicandthebatchno.ofvaccine;thedateofvaccinationshouldbeatleasttwoweekspriortogoingabroad)□麻疹預防接種證明VaccinationCertificatesofMeasles□彳魚國麻疹預防接植證明Vaccinatio