1、外国人体格检查记录Physical Examination Record For Foreigners姓 名Name性别Sex男 Male女 Female出生日期Birth Day-month-Year现在通讯地址Present mailing address血 型Blood type国 籍Nationality出生地址Birth Place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 following diseases？（Each item must be answered “Yes”or“No”）班 疹伤
2、 寒 Typhus fever NoYes 菌 痢 Bacillary dysentery NoYes小儿麻痹症 Poliomyelitis NoYes 布氏杆菌病 Brucellosis No Yes白 喉 Diphtheria NoYes 病毒性肝炎 Viral hepatitis No Yes猩 红 热 Scarlet ferver NoYes 产褥期链球菌 Puerperal streptococcus infection回 归 热 Relapsing fever No Yes 感 染 NoYes伤寒和付伤寒 Typhoid and paratyphoid fever NoYes流行性
3、脑脊髓膜炎 Epidemic cerebrospinal meningitis NoYes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 order and security?(Each item must be answered “Yes”or “No”)毒物瘾 Toxicomania . NoYes精神错乱 Mental confusion . NoYes精神病 Psychosis：躁狂型 Manic psyc
4、hosis . NoYes妄想型 Paranoid psychosis . NoYes幻觉型 Hallucinatory psychosis . NoYes身 高Height cm体 重Weight kg 血 压Blood pressure发育情况Development营养情况Nourishment颈 部Neek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Tonsil心Hear肺Lungs腹 部Abdomen脊 柱Spine四
5、肢Extremities神经系统Nervous system其它所见Other abnormal findings胸 部 X 线 检 查Chest X-ray exam心 电 图ECG化验室检查 包括血清学诊断Laboratoryexam(Serodiagnosis)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 开放性肺结核 Opening lung tuberculosis鼠 疫 Plague 艾 兹 病 AIDS麻 风 Leprosy 精 神 病 Psychosis意 见 检查单位盖章Suggestion Official Stamp医 师 签 字 日 期Signature of physician Date
