健康检查证明应检查项目表

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1、醫院標誌Hospital'sLogo健康檢查證明應檢查項目表（乙表）檢查日期//（年）（月）（日）(醫院名稱、地址、電話、傳真機)ITEMSREQUIREDFORHEALTHCERTIFICATE(FormB)(HospitaPsName,Address,Tel,FAX)基本資料（BASICDATA）姓名：Name*腔"：□男Male□女Female照片身份證字號護照號碼IDNo.:Passport:PhotoNo.出生年月曰.//國籍^DateofBirth*''Nationality•年齡.聯絡電話AgePhone

2、No.•實驗室檢查(LABORATORYEXAMINATIONS)(M)(D)(Y)DateofExaminationA.HIV抗體檢查(SerologicalTestforHIVAntibody):□陽性(Positive)□陰性(Negative)□未確定(Indeteirninate)a.篩檢(ScreeningTest)：QEIA(Z]PA□其他(Others)b.確認(ConfirmatoryTest):□WesternBlot□其他(Others)□兒童15歲以下免驗(Notrequiredforchild

3、renunder15yearsofage)B.胸部X光檢查肺結核(ChestX-RayforTuberculosis):X光發現(Findings):判定(Results)-□合格(Passed)□疑似肺結核(TBSuspect)□無法確認診斷(Pending)□不合格(Failed)(經臺灣健檢醫院判定為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。)(ThosewhoaredeterminedtobeTBsuspectsorhaveapendingdiagnos

4、isbythedesignatedhospitalinTaiwanmustvisitthereferredinstitutionforfurtherevaluation.)□孕婦或兒童12歲以下免驗(Notrequiredforpregnantwomenorchildrenunder12yearsofage)C・腸內寄生蟲(含痢疾阿米巴等原蟲)糞便檢查(採用離心濃縮法檢查XStoolexaminationforparasitesincludesEntamebahistolyticaetc.)(centrifugalco

5、ncentrationmethod):□陽性，種名(Positive,Species)□陰性(Negative)□其他可不予治療之腸內寄生蟲(Otherparasitesthatdonotrequiretreatment)□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(Tes⑸：

6、a.L1RPR或DVDRLb.EJTPHA/TPPAc.□其它(Other)判定(Resul⑸：□合格(Passed)□不合格(Failed)□兒童15歲以下免驗(Notrequiredforchildrenunder15yearsofage)E•麻疹及德國麻疹之抗體陽性檢驗報告或預防接種證明(proofofpositivemeaslesandrubellaantibodytitersormeaslesandrubellavaccinationcertificates):a.抗體檢查(Antibodytest)麻疹抗體

7、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VaccinationCertificates(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,thenameofadministeringhos

8、pitalorclinicandthebatchno.ofvaccine;thedateofvaccinationshouldbeatleasttwoweekspriortogoingabroad)□麻疹預防接種證明VaccinationCertificatesofMeasles□德國麻疹預防接種證明VaccinationCert