1、外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNR姓 名Name性别Sex口 男 Male口女 Female出生日期Birth Day-Month-Year现在通讯地址Present mailing address国 籍Nationality出生地址Birth place血型Bloodtype照 片（加盖检查单位印章）photostampedOfficial Stamp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 mus
2、t be answered “Yes” or “No”）斑疹伤寒 Typhus fever 口 No 口 Yes 菌 痢 Bacillary dysentery 口 No 口 Yes小尔麻痹症 Poliomyelitis 口 No 口 Yes 布氏杆菌病 Brucellosis 口 No 口 Yes白 喉 Diphtheria 口 No 口 Yes 病毒性肝炎 Viral hepatitis 口 No 口 Yes猩 红 热 Scarlet fever 口 No 口 Yes 产褥期链球 Puerperal streptococcus infection回 归 热 Relapsing 口 No 口
3、 Yes 菌 感 染 口 No 口 Yes伤寒和付寒 Typhoid and paratyphoid fever 口 No 口 Yes 口流行性脑脊髓炎 Epidemic cerebrospinal meningitis 口 No 口 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
4、瘾 Toxic mania 口 No 口 Yes 精神错乱 Mental confusion 口 No 口 Yes精 神 病 Psychosis:躁狂型 Manic Psychosis 口 No 口 Yes妄想型 Paranoid psychosis 口 No 口 Yes幻觉型 Hallucinatory psychosis 口 No 口 Yes身 高 厘米Height cm体 重 公斤Weight kg血 压 毫米汞柱Blood pressure mm Hg发育情况Development营养情况Nourishment颈部Neck视 力 左 LVision 右 R矫 正 视 力 左 LCorr
5、ected vision 右 R眼Eyes辩色力Color sense皮肤Skin淋巴结Lymph nodes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Nerous其他所见ther abnormal findings胸 部 X 线检 查 结 果（附检查报告单）Chest X-rayexam（ attachedchest X-ray report心 电 图CG化验室检查（包括 HIV 抗体、梅毒等血清学检查，并附原始报告单）Laboratory exam（Attached test report of A
6、IDS, Syphilis etc)1抗HIV(ELISA) 23梅毒血清凝集反应Syphilis serum agglutination reactionLiver functionHBsAgHBSAb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 disordere found during the present examination.霍 乱 Cholera 性 病 Venereal Disease黄热病 Yellow fever 开放性肺结核 Open lung tuberculosis鼠 疫 Plague 艾滋病 A
7、IDS麻 风 Leprosy 精 神 病 Psychosis（或 HIV 感染） （or HIV infected）意 见 检 验 检 疫 机 关 盖 章Suggestion: Stamp of Lnspection and Quarantine Service医 师 签 字 日 期Signature of physician: Date外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER体 检 说 明EXPLANATION OF THE PHYSICAL EXAMINATION1在华学习六个月以上的外国留学生，应按照“外国人体格检查记录”进行体
8、格检查。体检表贴照片处，应有医院印章，否则，视体检表无效。 The foreign students, who intend to study in China for more than 6 months, should go through a physical check-up before they come to China, according to the requirements of Physical Examination Record for Foreigners. The hospital seal should be put across the photo on t
9、he Examination Record, or the Record is invalid.2体检表应填写清楚，体检报告应附有 X 光透视胸片及霍乱、黄热、鼠疫、麻风、性病、开放性肺结核、艾滋病、肝功能、澳抗和精神病的化验室检查报告。外国留学生和专家到天津外国语学院报到时，我们将体检表及化验室检查报告送至天津市卫生检疫局查验。凡体检查验不合格者，需在天津市卫生检疫局重新体检，费用自理。 All the items of this form should be filled in carefully and clearly. The report should be attached wit
10、h the negative film for Chest X-ray exams, and the examination certificates for laboratory exams (Serodiagnosis), which include exams on Cholera, Yellow fever, Plague, Leprosy, Venereal Disease, Opening lung tuberculosis, AIDS, Psychosis, Liver function and HB&AG. On their arrival at Tianjin Foreign
11、 Studies University , the Record (a original copy) and laboratory exam certificates should be sent to Tianjin Quarantine Bureau for check. Those whose exam are not qualified should get the physical re-check up done in Tianjin . The expenses should be covered by themselves.3.体检应在来华一个月前在公立医院进行，凡在私立医院体
12、检者，应取得公证部门的公证。到达天津外国语学院报到时，体检时间不得超过六个月，否则应在天津重新检体，费用自理。.The physical examination should be taken in the public hospitals one month before their departure. If the physical check-up is done at a private hospital, the student or teacher should get the certificate notarized. If the physical check-up is
13、over 6 months old on the day of their registration, they should have re-check up in Tianjin . The expenses should be covered by themselves.4.体检表是办理入境签证及在华居留手续所需文件之一，留学生和专家到达天津外国语学院报到时，应提交正本。.The Physical Examination Form is one of the documents that is needed in the process of going through the visa formalities. The students and teachers should bring the original copy along with them when they come to Tianjin Foreign Studies University.
