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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照片 (加盖检查单位印章)Photo (Stamped OfficialStamp)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 m
2、ust be answered “Yes” or “No”)班 疹 伤 寒 Typhus fever No Yes 小儿麻痹症 Poliomyelitis No Yes 白 喉 Diphtheria No Yes 猩 红 热 Scarlet fever No Yes 回 归 热 Relapsing fever No Yes菌痢Bacillary dysenteryNo Yes布氏杆菌病BrucellosisNo Yes病毒性肝炎Viral hepatitisNo Yes产褥期链球Puerperal streptococcus infection菌感染No Yes伤寒和付伤寒Typhoid an
3、d paratyphoid feverNo Yes流行性脑脊髓膜炎Epidemic cerebrospinal meningitisNo 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Mental confusionNo Yes精神病 Psy
4、chosis: 躁狂型 Manic psychosisNo Yes 妄 想 型 Paranoid psychosisNo Yes 幻觉型 HallucinatoryNo Yes身高厘米HeightCM体重公斤WeightKg血压毫米汞柱Blood pressuremmHg发育情况Development营养情况Nourishment颈部Neck视力左 L Vision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Tonsils心Heart肺Lungs腹部Abdomen脊柱S
5、pine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ECG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SuggestionOfficial Stamp医师签字日期Signature of physicianDate
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