1、华东理工大学 East China University of Science and Technology外 国 人 体 格 检 查 记 录PHYSICAL EXAMINATION RECORD FOR FOREIGNER出 生 日 期Birth Day-Month-Year姓 名Name性别Sex男女MaleFemale现在通讯地址Present mailing address国 籍Nationality出生地址Birth Place血型Bloodtype照片Photo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 fol
2、lowing diseases?（Each item must be answered “Yes” or “No”）斑疹伤寒小儿麻痹症白喉猩红热Typhus feverPoliomyelitisDiphtheriaScarlet feverNoNoNoNoYesYesYesYes菌痢布氏杆菌病病毒性肝炎回归热Bacillary dysenteryBrucellosisViral hepatitisRelapsing feverNoNoNoNoYesYesYesYes产褥期链球菌感染 Puerperal streptococcus infection伤寒和付伤寒 Typhoid and para
3、typhoid fever流行性脑脊髓膜炎 Epidemic cerebrospinal meningitisNoNoNoYesYesYes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” ）Do you have any of the following diseases or disorders endangering the public orderand security? (Each item must be answered “Yes”or “No”)毒物瘾精神错乱精神病Toxicomania -Mental Confusion -Psychosis： 躁狂型
4、Manic psychosis -妄想型 Paranoid psychosis -幻觉型 Hallucinatory psychosis -NoNoNoNoNoYesYesYesYesYes身 高 厘米Height cm体 重 千克Weight Kg血 压 千帕Blood pressure Kpa发 育 情 况Development营 养 情 况Nourishment颈 部Neck视 力 左 LVision 右 R矫 正 视 力 左 LCorrected vision 右 R眼Eyes辨 色 力Colour sense皮 肤Skin淋 巴 结Lymph nodes耳Ears鼻Nose扁 桃 体
5、Tonsils心Heart肺Lungs腹 部Abdomen脊 柱Spine四 肢Extremities神 经 系 统Nervous system其 它 所 见Other abnormal findings胸部 X 线检查Chest Xrayexam.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：None of the following diseases or disorders found during the present examination.霍乱黄热病鼠疫麻风CholeraYellow feverPlagueLeprosy性病开放性肺结核艾滋病精神病Venereal DiseaseOpening lung tuberculosisAIDSPsychosis意 见Suggestion医 师 签 字Signature of physician检查单位盖章Official Stamp日 期Date
