外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
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姓 名
Name
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性别 □男Male
Sex □女Female
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出生日期
年
月
日
Date of Birth y.
m.
d.
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照片
photo
(put hospital seal across the photo)
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现在通讯地址
Present mailing address
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血型
Blood Type
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国籍
Natio-nality
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出生地
Birth Place
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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”)
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斑 疹 伤 寒 Typhus fever □No□Yes 细菌性痢疾 Bacillary dysentery □No□Yes
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小儿麻痹症Poliomyelitis □No□Yes 布氏杆菌病Brucellosis □No□Yes
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白 喉 Diphtheria □No□Yes 病毒性肝炎 Viral hepatitis □No□Yes
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猩 红 热Scarlet fever □No□Yes 产褥期链球菌 Puerperal streptococcus □NO□Yes
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回 归 热 Relapsing fever □No□Yes 感 染 infection □No□Yes
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伤寒和副伤寒 Typhoid and paratyphoid fever □No□Yes
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流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis □No□Yes
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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
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身 高/Height (厘米/ cm)
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体 重/ Weight (公斤/ kg)
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血压/pressure Blood(毫米汞柱/mmHg)
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发育情况Development
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营养情况Nourishment
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颈部Neck
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视 力
Vision
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左L
右R
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矫 正 视 力
Corrected vision
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左 L
右R
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眼Eyes
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辨 色 力/Color sense
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皮肤/Skin
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淋巴结/Lymph nodes
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耳/Ears
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鼻/Nose
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扁桃体/Tonsils
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心/Heart
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肺 /Lungs
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腹部/Abdomen
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编号：42 （19×27cm）
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脊柱/Spine
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四肢/Extremities
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神经系统/Nervous system
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其他所见
Other abnormal findings
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胸部X线检查/Chest X-ray exam
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心电图/ECG
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化验室检查(包括艾滋病、梅毒血清学诊断)/Laboratory Exam (HIV, Syphilis Serodiagnosis)
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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.
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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 Disease
黄热病 Yellow fever 开放性肺结核Opening lung tuberculosis
鼠 疫 Plague 艾 滋 病 AIDS
麻 风 Leprosy 精 神 病 Psychosis
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意 见 检查单位盖章
Suggestion Official Stamp
医师签字 日期
Signature of physician Date
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下载 Download: /uploadfile/201304/8/152666773.doc
