Health Check (Sample)

发布时间:2013年04月08日 阅读:

外国人体格检查记录

PHYSICAL EXAMINATION RECORD FOR FOREIGNER

姓 名
Name
 
 
性别 □男Male
Sex   □女Female
出生日期               
Date of Birth y.    m.    d.  
照片
photo
(put hospital seal across the photo)
现在通讯地址
Present mailing address
 
 
血型
Blood Type
 
国籍
Natio-nality
 
 
出生地
Birth Place
 
 
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”)
斑 疹 伤 寒 Typhus fever □No□Yes    细菌性痢疾 Bacillary dysentery             □No□Yes
小儿麻痹症Poliomyelitis  □No□Yes   布氏杆菌病Brucellosis                    □No□Yes
     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        □NO□Yes
回 归 热 Relapsing fever □No□Yes    感 染 infection                           □No□Yes
伤寒和副伤寒 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 secure?
(Each item most be answered “Yes”or“No”)
毒物瘾 Toxicomania………………………………………………………………………………□No□Yes
精神错乱Mental confusion ………………………………………………………………………□No□Yes
精神病Psychosis:躁狂型  Manic psychosis……………………………………………………□No□Yes
                妄想型  Paranoid psychosis…………………………………………………□No□Yes
                幻觉型 Hallucinatory psychosis……………………………………………□No□Yes
身 高/Height (厘米/ cm)
体 重/ Weight (公斤/ kg)
血压/pressure Blood(毫米汞柱/mmHg)
发育情况Development                                           
营养情况Nourishment                         
颈部Neck
 
 
视 力
Vision
左L
 
右R
矫 正 视 力
Corrected vision
左 L
 
右R
眼Eyes
辨 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

编号:42 (19×27cm)
 

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/Chest X-ray exam
 
心电图/ECG
 
化验室检查(包括艾滋病、梅毒血清学诊断)/Laboratory Exam (HIV, Syphilis Serodiagnosis)
附上对以下项目的化验室报告:Please attach the results and data sheets for the following items:AIDS.,Syphilis,ALT.,AST.,T-BIL.,and HBsAG.
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                               病 Venereal Disease
黄热病 Yellow fever                   开放性肺结核Opening lung tuberculosis
鼠 疫 Plague                              病 AIDS
麻 风 Leprosy                             病 Psychosis
 
意 见                                              检查单位盖章
 Suggestion                                           Official Stamp
 
                          
 
 
 
 
 
 
 
 医师签字                                            日期
Signature of physician                                        Date

 

下载 Download:  /uploadfile/201304/8/152666773.doc


通讯地址:中国江苏省南京市仙林大学城文苑路3号 行政楼14楼,邮编:210023
咨询电话:025 - 86718741. 中外合作办学预科招生