外国人体格检查表

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

Physical Examination Record for Foreigner

斑疹伤寒小儿麻痹症白猩回红归喉热热 Typhus fever Poliomyelitis Diphtheria Scarlet fever Relapsing fever 伤寒和副伤寒 □No □No □No □No □No □Yes □Yes □Yes □Yes □Yes 菌痢 Bacillary dysentery Brucellosis Viral hepatitis □ No □ No □ No □Yes □Yes □Yes □Yes
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
kg
血压 Blood pressure 颈部 Neck 眼 Eyes 淋巴结 Lymph nodes 扁桃体 Tonsils 腹部 Abdomen
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”）
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.
霍黄鼠麻热乱病疫风 Cholera Yellow fever Plague Leprosy 性艾精滋神病病病 Venereal Disease Opening lung tuberculosis AIDS Psychosis

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 - STUDY IN CHINA 来华留学联盟

照片photo斑疹伤寒 Typhus fever □No □Yes 菌痢 Bacillary dysentery □No □Yes现在通信地址Present mailing address血型 Blood TypeBlood pressure mmHg 伤寒和付伤寒 Typhoid and paratyphoid fever □No □Yes 流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis □No □Yesorder and security? (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 ofthe following diseases of disorders endangering the publicAbdomenLymph nodes 扁桃体 Tonsils 腹部颈部 Neck 眼 Eyes 淋巴结LungsHeart营养情况 Nourishment矫正视力左 L Corrected vision R 皮肤 Skin 鼻 Nose 肺 Colour sense 耳 Ears 心出生地址Place of BirthWeight kg 发育情况 Development 身高厘米 Height cm 过去是否患有下列疾病：（每项后面请回答“否”或“是”）(Each item must be answered “Yes ”or “No ”)Have you ever had any of the following diseases? 妄想型 Paranoid psychosis ……………………………□No □Yes 国籍Nationality体重公斤毒物瘾 Toxicomania …………………………………………………………… □No □Yes 精神错乱 Mental confusion …………………………………………………… □No □Yes 精神病 Pyschosis: 躁狂型 Manic psychosis ………………………………□No □Yes 血压毫米汞柱出生日期 Date of BirthYr no dayVision R 辨色力幻觉型 Hallucinatory psychosis b ……………………□No □Yes猩红热 Scarlet fever □No □Yes 产褥期链球病 Puerperal streptococcus infection 白喉 Diphtheria □No □Yes 病毒性肝炎 Viral hepatitis □No □Yes 小儿麻痹症 Poliomyelities □No □Yes 布氏杆菌病 Brucellosis □No □Yes视力左 L 回归热 Relapsing fever □No □Yes 感染 □No □Yes 外国人体格检查记录PHYSICL EXAMTNATION RECORD FOR FOREIGNER姓名Full Name性别Sex□男 Male □女 FemalePDF created with FinePrint pdfFactory trial version 。

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

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

(ERPMRP管理)外国人体格检查表FOREIGNERPHYS

血型
Blood
type
国籍或地区
Nationality
(or Area)
出生地址
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 deseases?
(Each item must be answered “Yes” or “No”)
精神错乱Metal confusion………………………………………………………………□No□Yes
精神病Psychosis：躁狂型Manic Paychosis………………………………………□No□Yes
妄想型 psychosis………………………………………□No□Yes
幻想型Hallucinatorypsychosis……………………………………□No□Yes
Do you have any of the following diseases or disorders endangering the public order and security?
(Each item must be answered “Yes” of “No”)
毒物瘾Toxicomania………………………………………………………………………□No□Yes
身高厘米
Height CM
体重公斤
Weight kg
血压毫米汞柱
Blood pressure mmHg
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_______

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

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