外国人体格检查表.doc

外国人体格检查表 PHYSICAL EXAMINATION RECORD FOR FOREIGNERS姓名Name性别Sex 男 Male 女 Female出生日期Date of birth照片 Photo现在通讯地址Present mailing address 血型Blood type国籍Nationality出生地址Birth Place 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 disease? （Each item must be answered “Yes” or “No”）斑疹伤寒Typhus fever No Yes 菌痢Bacillary dysentery