1、外 国 人 体 格 检 查 表FOREIGNER PHYSICAL EXAMINATION FORM姓名Name性别Sex 男 Male 女 Female出生日期Birthday现在通讯地址Present mailing address国籍或地区 Nationality (or Area)出生地 Birth place血型Blood type照片(加盖检查 单 位印章 )Photo(Stamped OfficialStamp)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 ite
2、m must be answered “Yes” or “No”)班疹 伤寒 Typhus fever No Yes 菌 痢 Bacillary dysentery No Yes小儿麻痹症 Poliomyelitis No Yes 布氏杆菌病 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
3、付伤寒 Typhoid and paratyphoid fever No Yes流行性脑脊髓膜炎 Epidemic cerebrospinal 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 diseases or disorders endangering the public order and security? (Each item must be answered “Yes” or “No”)毒物瘾 ToxicomaniaNo Yes精神错乱 Ment
4、al confusionNo Yes 精神病 Psychosis：躁 狂型 Manic paychosisNo Yes妄想型 Paranoid psychosisNo Yes幻觉型 HallucinatoryNo Yes身高 厘米Height CM体重 公斤Weight Kg血压 毫 米汞柱Blood pressure mmHg发育情况Development营养情况Nourishment颈部Neck视力 左 LVision 右 R矫正视力 左 L Corrected 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其他所见Other abnormal findings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 ECC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)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 of 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意 见 检查单位盖章Suggestion Official Stamp医师签字 日期Signature of physician Date
