-
外国人体格检查表
PHYSICAL EXAMINATION RECORD FOR FOREIGNERS
附表:外国人体格检查表
(其中肝功能、胸透、澳亢、艾滋病为必检项目)
Appendix : The Physical Examination
Record for Foreigner (Liver function, chest X-ray
and
AIDS are required items)
姓名
Name
性别
□
男
Male
Sex
□
女
Female
出生地址
Birth Place
出生日期
Date
of
birth
血型
Blood type
照片
Photo
现在通讯地址
Present
mailing address
国籍
Nationality
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 disease?
(
Each item must be answered
“
Yes
”
or
“
No
”
)
斑疹伤寒
Typhus
fever
□
No
□
Yes
菌痢
Bacillary dysentery
□
No
□
Yes
小儿麻痹症
Poliomyelitis
□
No
□
Yes
布氏杆菌
Brucellosis
□
No
□
Yes
白喉
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
infection
回归热
Relapsing fever
□
No
□
Yes
□
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 disease or disorders endangering the
public order and
security?
(
Each item must be answered
“
Yes
”
or
“
No
”
)
毒物瘾
Toxicomania
--------------------------------------------------
--
□
No
□
Yes
精神错乱
Mental confusion--------
-------------------------------------
□<
/p>
No
□
Yes
精神病
Psychosis
:狂躁型
Manic psychosis
------------------------------
□
< br>No
□
Yes
妄想型
Paranoid psychosis-------
---------------------
□
No
□
Yes
幻觉型
Hallucinatory psychosis--
---------------------
□
No
□
Yes
身高
Height
cm
发育情况
Development
视力
左
L
Vision
右
R
辨色力
Color sense
耳
Ears
体重
Weight
营养状况
Nourishment
矫正视力
左
L
Corrected
vision
右
R
皮肤
Skin
鼻
Nose
血压
Blood pressure
颈部
Nest
眼
Eyes
淋巴结
Lymph nods
扁桃体
Tonsils