外國(guó)人體格檢查表

1、外國(guó)人體格檢查表FEIGNERPHYSICALEXAMINATIONFM姓名Name性別Sex□男Male□女Female出生日期Birthday現(xiàn)在通訊地址Presentmailingaddress國(guó)籍或地區(qū)Nationality(Area)出生地Birthplace血型Bloodtype照片(加蓋檢查單位印章)Photo(StampedOfficialStamp)過(guò)去是否患有下列疾病（每項(xiàng)后面請(qǐng)回答“否”或“是”）Haveyouev

2、erhadanyofthefollowingdiseases(Eachitemmustbeanswered“Yes”“No”)班疹傷寒Typhusfever□No□Yes菌痢Bacillarydysentery□No□Yes小兒麻痹癥Poliomyelitis□No□Yes布氏桿菌病Brucellosis□No□Yes白喉Diphtheria□No□Yes病毒性肝炎Viralhepatitis□No□Yes猩紅熱Scarletfever

3、□No□Yes產(chǎn)褥期鏈球Puerperalstreptococcusinfection回歸熱Relapsingfever□No□Yes菌感染□No□Yes傷寒和付傷寒Typhoidparatyphoidfever□No□Yes流行性腦脊髓膜炎Epidemiccerebrospinalmeningitis□No□Yes是否患有下列危及公共秩序和安全的病癥：(每項(xiàng)后面請(qǐng)回答“否”或“是”)Doyouhaveanyofthefollowing

4、diseasesdisdersendangeringthepublicdersecurity(Eachitemmustbeanswered“Yes”“No”)毒物癮Toxicomania…………………………………………………□No□Yes精神錯(cuò)亂Mentalconfusion……………………………………………□No□Yes精神病Psychosis：躁狂型Manicpaychosis…………………………………□No□Yes妄想型Paran

5、oidpsychosis………………………………□No□Yes幻覺(jué)型Hallucinaty……………………………………□No□Yes身高厘米HeightCM體重公斤WeightKg血壓毫米汞柱BloodpressuremmHg發(fā)育情況Development營(yíng)養(yǎng)情況Nourishment頸部Neck視力左LVision右R矯正視力左LCrectedvision右R眼Eyes辨色力Coloursense皮膚Skin淋巴結(jié)Lymphnodes

6、耳Ears鼻Nose扁桃體Tonsils心Heart肺Lungs腹部Abdomen脊柱Spine四肢Extremities神經(jīng)系統(tǒng)Nervoussystem其他所見(jiàn)Otherabnmalfindings胸部X線檢查結(jié)果(附檢查報(bào)告單)ChestXrayexam(attachedchestXrayrept)心電圖ECC化驗(yàn)室檢查(包括艾滋病、梅毒等血清學(xué)檢查)Labatyexam(attachedtestreptofAIDSSyphili

7、setc)未發(fā)現(xiàn)患有下列檢疫傳染病和危害公共健康的疾病:Noneofthefollowingdiseasesofdisdersfoundduringthepresentexamination.霍亂Cholera性病VenerealDisease黃熱病Yellowfever肺結(jié)核Lungtuberculosis鼠疫Plague艾滋病AIDS麻風(fēng)Leprosy精神病Psychosis意見(jiàn)檢查單位蓋章SuggestionOfficialSta