外国人体格检查表
外 国 人 体 格 检 查 记 录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
姓 名 Name |
性别 Sex |
□男 Male □女 Female |
出生日期\ Birth Day-Month-Year |
照片加盖医院 公章 Photo with hospital stamp |
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现在通讯地址 Present mailing address |
血型 Blood type |
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国 籍 Nationality |
出生地址 Birth Place |
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过去是否患有下列疾病：（每项后面请回答“否”或“是”） Have you ever had any of the following diseases? (Each item must be answered “yes” or “No” 斑 疹 伤寒 Typhus fever □No □Yes 菌 痢 Bacillary dysentery □No □Yes 小儿麻痹症 Poliomyelitis □No □Yes 布氏杜菌病 Brucellosis □No □Yes 白 喉 Diphtheria □No □Yes 病毒性肝炎 Viral hepatitis □No □Yes 猩 红 热 Scarlet fever □No □Yes 产褥期链球 Puerperal streptococcus infection 回 归 热 Relapsing fever □No □Yes 菌 感 染 □No □Yes 伤寒和付伤寒 Typhoid and paratyphoid fever □No □Yes 流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis □No □Yes |
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是否患有下列危及公共秩序和安全的疾病：（每项后面请回答“否”或“是”） Do you have any of the following diseases or disorders endangering the pubic order and security? (Each item must be answered “Yes” or “No”) 毒 物 瘾 Toxicomania………………………………………………………………………………□No □Yes 神经错乱 Mental confusion…………………………………………………………………………□No □Yes 神 经 病 Psychosis: 躁狂型 Manic psychosis……………………………………………………□No □Yes 妄想型 Paranoid psychosis…………………………………………………□No □Yes 幻想型 Hallucinatory psychosis……………………………………………□No □Yes |
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身高 厘米 Height cm |
体重 公斤 Weight kg |
血压 千帕 Blood pressure KPa |
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发育情况 Development |
营养情况 Nourishment |
颈部 Neck |
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视力 左L Vision 右R |
矫正视力 左L Corrected vision 右R |
眼 Eyes |
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辨色力 Colour sense |
皮肤 Skin |
淋巴结 Lymph nodes |
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耳 Ears |
鼻 Nose |
扁桃体 Tonsils |
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心 Heart |
肺 Lungs |
腹部 Abdomen |
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脊 柱 Spine |
四 肢 Extremities |
神经系统 Nervous system |
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其它所见 Other abnormal findings |
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胸 部 X 线 检 查 结 果 （附检查报告单） Chest X-ray Exam (Attached chest X-ray report |
心电图 ECG |
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化 验 室 检 查 （包括艾滋病、梅毒等血清学检查） Laboratory exam (Attached test report of AIDS, Syphilis etc) |
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未发现患有下列检疫传染病和危害公共健康的疾病： None of the following diseases or disorders found during the present examination 霍 乱 Cholera 性 病 Venereal Disease 黄热病 Yellow fever 肺结核 lung tuberculosis 鼠 疫 Plague 艾滋病 AIDS 麻 风 Leprosy 精神病 Psychosis |
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意 见 检查单位盖章 Suggestion Official Stamp 医师签字 日期 Signature of physician Date |
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