外国人体格检查表
合集下载
PHYSICAL EXAMINATION RECORD FOR FOREIGNERS
（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
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”）
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
odiagnosis）
未发现患有下列检疫传染病和危害公共健康的疾病
毒物瘾Toxicomania----------------------------------------------------□No□Yes
精神错乱Mental confusion---------------------------------------------□No□Yes
精神病Psychosis：狂躁型Manic psychosis------------------------------□No□Yes
妄想型Paranoid psychosis----------------------------□No□Yes
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
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”）
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
odiagnosis）
未发现患有下列检疫传染病和危害公共健康的疾病
毒物瘾Toxicomania----------------------------------------------------□No□Yes
精神错乱Mental confusion---------------------------------------------□No□Yes
精神病Psychosis：狂躁型Manic psychosis------------------------------□No□Yes
妄想型Paranoid psychosis----------------------------□No□Yes
外国人体格检查记录【模板】
Kg /Blood pressure mmHg
发育情况
营养情况
颈部
Development
Nourishment
Neck
视力 Vision
左L 右R
矫正视力
左L
眼
Corrected vision 右 R
Eyes
辨色力 Color sense
皮肤 Skin
淋巴结 Lymph nodes
耳 Ears
心 Heart
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 Toxicomania
血型 Blood
Type
照 片 Photo
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 菌
□No□Yes
精神错乱 Mental confusion
□No□Yes
精 神 病 Psychosis: 燥狂型 Manic
□No□Yes
妄想型 Paranoid
□No□Yes
幻觉型 Hallucinatory psychosis
□No□Yes
身高
厘米 体 重
公斤 血 压
毫米汞柱
外国人体检表
外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓名 Name性别□男Male Sex □女 Female 岀生日期 年 月 日Date of Birth y. m. d. 现在通迅地址 Prese nt maili ng adderss 血型 Blood Type国籍 Nation ality出生地 Birth Place （Put ospital seal across the photo ）照片 Photo 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 followi ng diseases?（Each ietm must be an swered Yes"or No"No Yes No | — Yes 斑疹伤寒 Typhus fever —N O — Yes 细菌性痢疾 Bacillary dysentery 小儿麻痹症 Poliomyelitis '— N O | Yes 布氏杆菌病 Brucellosis 匚 No 二 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 — N O [_ Yes 回归热Relapsing fever | NO Yes 感 染『fection _J No — Yes Diphtheri a 伤寒和副伤寒 Typhoid and paratyphoid fever_ No | Yes 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 follow ing diseases or disorders endan geri ng the public order and secure? （Each item most be answered Yes" or No ”）毒物瘾 Toxicomani a …精神错乱 Me ntal co nfusi on 精神病Psychosis ：躁狂型 妄想型幻觉型 流行性脑脊髓膜炎 Epidemic cerebrosp inal menin gitisManic psychosis …• Paranoid psychosis • Halluc in atorypsychosis □ No □Yes □ No □ Yes □ No □ Yes □ No □ Yes □ 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 Developme nt营养情况 Nourishme nt 颈部Neck视力 Visio n 辨色力 /Color sense 矫正视力 Corrected visio n 皮肤/Skin耳 /Ears 鼻 /Nose 心 /Heart肺/Lungs 眼 Eyes淋巴结 /Lymph nodes扁桃体/Tonsils腹部 /Abdomen（注：表格素材和资料部分来自网络，供参考。
外国人体格检查记录
// D/M/Y
照 片 Photo
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 “No” or “Yes”)
斑疹伤寒 Typhus fever □否/No □是/Yes
□否/No □是/Yes □否/No □是/Yes □否/No □是/Yes □否/No □是/Yes
是否患有下列危机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 “No” or “Yes”)
外国人体格检查记录
PHYSICAL EXMINATION RECORD FOR FOREIGNER
姓名 Name
现住址 Address 国籍 Nationality
性别 Sex
□男 Male 出生日期 □女 Female Birth D/M/Y
出生地 Birth place
血型 Blood type
□否/No
霍乱 Cholera
性病
Venereal diseases
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
□是/Yes
意见 Suggestion
外国人体格检查记录 - Embassy of the People's Republic …
神经系统 Nervous system
胸部 X 线 检查 Chest X-ray Exam.
心 电 图
E C G
化验室检查 包括血清学诊断 Laboratory Exam. (Serodiagnosis)
是否发现患有下列检疫传染病和危害公共健康的疾病:
Do you have any of the following diseases or disorders found during the present examination?
（Each item must be answered “Yes” or “No”）
霍 黄 鼠 麻 乱 热 病 疫 风 Cholera Yellow fever Plague Leprosy □No □No □No □No □Yes □Yes □Yes □Yes 性 艾 精 滋 神 病 病 病 Venereal Disease AIDS Psychosis □No □Yes □No □Yes □No □Yes
Psychosis: 躁狂型 Manic Psychosis 妄想型 Paranoid Psychosis
幻觉型 Hallucinatory Psychosis
身高 Height 发育情况 Development 视力 Vision 左 L 右 R
cm
体重 Weight 营养情况 Nourishment 矫正视力 Corrected vision 皮肤 Skin 鼻 Nose 肺 Lungs 左 L 右 R
Birth Day-Month-Year
照 血 型 Blood type 片 Photo
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”）
外国人体格检查表-中华人民共和国外交部
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
（包括血清学诊断）
Laboratory
Exam
（Serodiagnosis）
未发现患有下列检疫传染病和危害公共健康的疾病
外国人体格检查表
PHYSICAL EXAMINATION RECORD FOR FOREIGNERS
姓名
Name
性别
Sex
□男Male
□女Female
出生日期
Date of birth
照片
Photo
现在通讯地址
Present mailing address
血型
Blood type
国籍
Nationality
None of the following diseases or disorders found during the present examination
霍乱Cholera性病Venereal
黄热病Yellow fever开放性肺结核Opening lung tuberculosis
鼠疫Plague爱滋病AIDS
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
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
（包括血清学诊断）
Laboratory
Exam
（Serodiagnosis）
未发现患有下列检疫传染病和危害公共健康的疾病
外国人体格检查表
PHYSICAL EXAMINATION RECORD FOR FOREIGNERS
姓名
Name
性别
Sex
□男Male
□女Female
出生日期
Date of birth
照片
Photo
现在通讯地址
Present mailing address
血型
Blood type
国籍
Nationality
None of the following diseases or disorders found during the present examination
霍乱Cholera性病Venereal
黄热病Yellow fever开放性肺结核Opening lung tuberculosis
鼠疫Plague爱滋病AIDS
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
外国人体格检查记录
斑 疹 伤 寒 Typhus fever
□No □Yes 菌 痢 Bacillary dysentery
□No □Yes
小儿麻痹症 Pollomyclitis
□No □Yes 布氏杆菌病 Bruccllosis
□No □Yes
白
喉 Diphtheria
□No □Yes 病毒性肝炎 Viral hepatitis
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
意见
检查单位盖章
Suggestion
Official Stamp
医师签字 Signature of Physician
Blood
片
国籍 Nationality
出生地址 Birth Place
type
Photo
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”)
□No □Yes
流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis □No □Yes
是否患有下列危及公秩序和安全的病症：（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?
外国人体格检查记录+模板
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 鼠 麻 乱 疫 风 Cholera Yellow fever Plague Leprosy 性 病 Venereal Disease lung tuberculosis AIDS Psychosis
辨色力 Colour sense 耳 Ears 心 Heart
脊
柱
四
肢
神经系统 Nervous system
Spine 其它所见 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
照
片
（加盖检查 单位印章）
产褥期链球 Puerperal streptococcus infection
伤寒和付伤寒
Typhoid and paratyphoid fever Epidemic cerebrospinal meningitis
流行性脑脊髓膜炎
是否患有下列危及公共秩序和安全的疾病： （每项后面请回答“否”或“是” ） Do you have any of the following diseases or disorders endangering the pubic order and security? (Each item must be answered “Yes” or “No”) 毒 物 瘾 神经错乱 神 经 病 Toxicomania………………………………………………………………………………□No □Yes Mental confusion…………………………………………………………………………□No □Yes Psychosis: 躁狂型 Manic psychosis……………………………………………………□No □Yes 妄想型 Paranoid psychosis…………………………………………………□No □Yes 幻想型 Hallucinatory psychosis……………………………………………□No □Yes 身高 Height 发育情况 Development 视力 Vision 左L 右R 厘米 cm 体重 Weight 营养情况 Nourishment 矫正视力 Corrected vision 皮肤 Skin 鼻 Nose 肺 Lungs 左L 右R 公斤 kg 血压 Blood pressure 颈部 Neck 眼 Eyes 淋巴结 Lymph nodes 扁桃体 Tonsils 腹部 Abdomen 千帕 KPa
上海外国语大学 外国人体格检查记录表
脊柱 Spine
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)
四肢 Extremities
神经系统 Nervous system
心电图 ECC
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)
(Each item must 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 paychosis…………………………………□No □Yes
Bacillary dysentery □No □Yes
Brucellosis Viral hepatitis
□No □Yes □No □Yes
Puerperal streptococcus infection
□No □Yes
伤寒和付伤寒
Typhoid and paratyphoid fever
□No □Yes
班疹 伤寒
小儿麻痹症
白
喉
猩红热
回归热
Typhus fever □No □Yes Poliomyelitis □No □Yes Diphtheria □No □Yes Scarlet fever □No □Yes Relapsing fever □No □Yes
外国人体格检查表.docx
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 must be answered “Yes” or “No”)
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”)
霍乱Cholera性病VenerealDisease
黄热病Yellowfever肺结核Lungtuberculosis
鼠疫Plague艾滋病AIDS
麻风Leprosy精神病Psychosis
意 见 检查单位盖章
Suggestion OfficialStamp
医师签字 日期
Signatureofphysician Date
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.
毒物瘾Toxicomania…………………………………………………□No□Yes
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 must be answered “Yes” or “No”)
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”)
霍乱Cholera性病VenerealDisease
黄热病Yellowfever肺结核Lungtuberculosis
鼠疫Plague艾滋病AIDS
麻风Leprosy精神病Psychosis
意 见 检查单位盖章
Suggestion OfficialStamp
医师签字 日期
Signatureofphysician Date
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.
毒物瘾Toxicomania…………………………………………………□No□Yes
外国人入境体格检查表.doc
毒 瘾 Toxicomania …………………………………………………………. No Yes 精神错乱 Mental confusion …………………………………………………….. No Yes 精 神 病 Psychosis: 躁狂型 Manic psychosis ……………………………….. No Yes
ቤተ መጻሕፍቲ ባይዱ
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
Yes 产褥期链球菌感染 Yes Puerperal streptococcus infection
流行性脑脊髓膜炎
Typhoid or paratyphoid fever No Yes Epidemic cerebrospinal meningitis
照片 Photo
No Yes No Yes No Yes No Yes No Yes
外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNERS
姓名 Name
现在通讯地址 Present mailing address 国籍
性
男 Male
别
Sex
女 Female
出生地址
出生日期 Birth Day-Month-Year
血型 Blood Type
厘米 cm
左L 右R
体重
公斤
Weight
kg
ቤተ መጻሕፍቲ ባይዱ
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
Yes 产褥期链球菌感染 Yes Puerperal streptococcus infection
流行性脑脊髓膜炎
Typhoid or paratyphoid fever No Yes Epidemic cerebrospinal meningitis
照片 Photo
No Yes No Yes No Yes No Yes No Yes
外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNERS
姓名 Name
现在通讯地址 Present mailing address 国籍
性
男 Male
别
Sex
女 Female
出生地址
出生日期 Birth Day-Month-Year
血型 Blood Type
厘米 cm
左L 右R
体重
公斤
Weight
kg
外国人体格检查记录
回归热Relapsing fever□No□Yes菌感染□No□Yes
伤寒和付伤寒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 security?
(Each item must be answered “Yes” or “No”)
毒物瘾Toxicomania………………………………………………………………………□No□Yes
幻觉型Hallucinatory psychosis……………………………………□No□Yes
身高厘米
Height cm
体重公斤
Weight kg
血压千帕
Blood pressure KPa
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
斑疹伤寒Typhus fever□No□Yes菌痢Bacillary dysentery□No□Yes
小儿麻痹症Poliomyelitis□No□Yes布氏杆菌病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Puerperal streptococcus infection□No□Yes
伤寒和付伤寒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 security?
(Each item must be answered “Yes” or “No”)
毒物瘾Toxicomania………………………………………………………………………□No□Yes
幻觉型Hallucinatory psychosis……………………………………□No□Yes
身高厘米
Height cm
体重公斤
Weight kg
血压千帕
Blood pressure KPa
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
斑疹伤寒Typhus fever□No□Yes菌痢Bacillary dysentery□No□Yes
小儿麻痹症Poliomyelitis□No□Yes布氏杆菌病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Puerperal streptococcus infection□No□Yes
外国人体格检查记录-EmbassyofthePeople'sRepublicof
外国人体格检查记录
Physical Examination Record for Foreigner
姓名 Name
性别 Sex
□男 Male
出生日期
□女 Female Birth Day-Month-Year
现在通讯地址 Present Mailing Address
国籍 Nationality
出生地址 Birth Place
（Each item must be answered “Yes” or “No”）
身高 Height
发育情况 Development
视力 左 L Vision 右 R
辨色力 Colour Sense
体重
cm
Weight
kg
营养情况 Nourishment
矫正视力
左L
Corrected vision 右 R
Plague Leprosy
性
病
开放性肺结核
艾滋病
精神病
Venereal Disease Opening lung tuberculosis
AIDS Psychosis
意见 Suggestion
检查单位盖章 Official Stamp
医师签字 Signature of Physician
日期 Date
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 must be answered “Yes” or “No”）
照 片 Photo
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？
Physical Examination Record for Foreigner
姓名 Name
性别 Sex
□男 Male
出生日期
□女 Female Birth Day-Month-Year
现在通讯地址 Present Mailing Address
国籍 Nationality
出生地址 Birth Place
（Each item must be answered “Yes” or “No”）
身高 Height
发育情况 Development
视力 左 L Vision 右 R
辨色力 Colour Sense
体重
cm
Weight
kg
营养情况 Nourishment
矫正视力
左L
Corrected vision 右 R
Plague Leprosy
性
病
开放性肺结核
艾滋病
精神病
Venereal Disease Opening lung tuberculosis
AIDS Psychosis
意见 Suggestion
检查单位盖章 Official Stamp
医师签字 Signature of Physician
日期 Date
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 must be answered “Yes” or “No”）
照 片 Photo
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？
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病毒性肝炎Viralhepatitis□No□Yes
产褥期链球Puerperal streptococcusinfection
菌感染□No□Yes
伤寒和付伤寒Typhoidand paratyphoidfever□No□Yes
流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□No□Yes
None of the following diseases of disorders found during the present examination.
霍乱Cholera性病VenerealDisease
黄热病Yellowfever肺结核Lungtuberculosis
鼠疫Plague艾滋病AIDS
班疹伤寒Typhusfever□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Bacillarydysentery□No□Yes
布氏杆菌病Brucellosis□No□Yes
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 Official
Stamp)
现在通讯地址
Present mailing address
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
Spine
四肢
Extremities
神经系统
Nervous system
X线检查结果(附检查报告单)
幻觉型Hallucinatory……………………………………□No□Yes
身高厘米
HeightCM
体重公斤
WeightKg
血压毫米汞柱
BloodpressuremmHg
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
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 must be answered “Yes” or “No”)
Chest X-ray exam (attached chest X-ray report)
心电图ECC
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:
毒物瘾Toxicomania…………………………………………………□No□Yes
精神错乱Mentalconfusion……………………………………………□No□Yes精神病Psychosis：躁狂型Manicpaychosis…………………………………□No□Yes妄想型Paranoid psychosis………………………………□No□Yes
麻风Leprosy精神病Psychosis
意见检查单位盖章
SuggestionOfficialStamp
医师签字日期
SignatureofphysicianDate
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”)
产褥期链球Puerperal streptococcusinfection
菌感染□No□Yes
伤寒和付伤寒Typhoidand paratyphoidfever□No□Yes
流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□No□Yes
None of the following diseases of disorders found during the present examination.
霍乱Cholera性病VenerealDisease
黄热病Yellowfever肺结核Lungtuberculosis
鼠疫Plague艾滋病AIDS
班疹伤寒Typhusfever□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Bacillarydysentery□No□Yes
布氏杆菌病Brucellosis□No□Yes
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 Official
Stamp)
现在通讯地址
Present mailing address
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
Spine
四肢
Extremities
神经系统
Nervous system
X线检查结果(附检查报告单)
幻觉型Hallucinatory……………………………………□No□Yes
身高厘米
HeightCM
体重公斤
WeightKg
血压毫米汞柱
BloodpressuremmHg
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
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 must be answered “Yes” or “No”)
Chest X-ray exam (attached chest X-ray report)
心电图ECC
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:
毒物瘾Toxicomania…………………………………………………□No□Yes
精神错乱Mentalconfusion……………………………………………□No□Yes精神病Psychosis：躁狂型Manicpaychosis…………………………………□No□Yes妄想型Paranoid psychosis………………………………□No□Yes
麻风Leprosy精神病Psychosis
意见检查单位盖章
SuggestionOfficialStamp
医师签字日期
SignatureofphysicianDate
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”)