外国人体格检查记录

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1、外国人体格检查记录PHYSICALEXAMENATIONRECORDFORFOREIGNER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：（每项后请回答“否”或“是”）Haveyoueverhadanyofthefollowingdiseases?(Eachitemmustbeanswered

2、“yes”or“No”)斑疹伤寒Typhusfever□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Scarletfever□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Typho

3、idandparatyphoidfever□No□Yes流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□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”）Doyouhaveanyofthefollowingdeseasesordisordersendangeringthepublicorderandsecurity?(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身高厘米Heightcm体重　　　　　　　　　　公斤Weightkg血压　毫米贡柱Bloodpressur

5、emmHg发育情况Development营养情况Nourishment颈部Neck视力左Ｌ　　　Vision右Ｒ　　矫　正　视　力　左　Ｌ　　　Correctedvision　右　Ｒ　　　眼Eyes辨　色　力Coloursense皮　肤Skin淋　巴　结Lymphnodes耳Ears鼻Nose扁桃体Tonsils心Ｈeart肺Lungs腹　部Ａbdomen脊柱四肢神经系统SpineExtremitiesNervoussystem其它所见Otherabonrmalfindings胸部Ｘ线检查ChestX-ray

6、exam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VenerealDisease黄热病　Yellowfever　开放性肺结核Openinglungtuberculosis鼠疫　Plague　艾滋病AIDS麻风　Lepr

7、osy　精神病Psychosis意见检查单位盖章SuggestionOfficialStamp医师签字　　　　　　　　　　　　　　　　　　　　　　　　日　期SignatureofphysicianDate注意：入境时请您携带此检查记录，胸部“Ｘ”光片及血液化验报告（均为原件）。Note:PleasebringwithyouthisRecord,ChestX-rayexamandBloodReportwhenyoucometoChina.(alltheseshouldbeoriginals)