1、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 disease?（Each item must be answered “Yes” or “No”）斑疹伤寒 Typhus fe
2、ver No Yes 菌痢 Bacillary dysentery No Yes小儿麻痹症 Poliomyelitis No Yes 布氏杆菌 Brucellosis No Yes白喉 Diphtheria No Yes 病毒性肝炎 Viral hepatitis No Yes猩红热 Scarlet fever No Yes 产褥期链球菌 Puerperal streptococcus infection回归热 Relapsing fever No Yes No Yes伤寒和副伤寒 Typhoid and paratyphoid fever No Yes流行性脑脊髓膜炎 Epidemic ce
3、rebrospinal meningitis 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”）Do you have any of the following disease or disorders endangering the public order and security?（Each item must be answered “Yes” or “No”）毒物瘾 Toxicomania-No Yes精神错乱 Mental confusion-No Yes精神病 Psychosis：狂躁型 Manic psychosis-No Yes妄想型 Para
4、noid psychosis-No Yes幻觉型 Hallucinatory psychosis-No Yes身高Height cm体重Weight血压Blood pressure发育情况Development营养状况Nourishment颈部Nest视力 左 LVision 右 R矫正视力 左 LCorrected vision 右 R眼E辨色力Color sense皮肤Skin淋巴结Lymph nods耳Ears鼻Nose扁桃体Tonsils心Heart肺Lungs腹部Abdomen脊柱Spine四肢Extremities神经系统Nervous system其他所见Other abnorm
5、al findings胸部 X 线检查Chest Xray 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黄热病 Yellow fever 开放性肺结核 Opening lung tuberculosis鼠 疫 Plague 爱 滋 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
