外国人体格检查表FOREIGNERPHYS

外国人体格检查记录

外国人体格检查记录Physical Examination Record for Foreigner姓名性别□男Male 出生日期Name Sex □女Female Birth Day-Month-Year照现在通讯地址血型Present Mailing Address Blood 片国籍出生地址typePhotoPlaceNationality Birth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 □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 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身高体重血压Height cm Weight kg Blood pressure mmHg发育情况营养情况颈部Development Nourishment Neck视力左L 矫正视力左L 眼右R EyesVision 右R Correctedvision辨色力皮肤淋巴结Colour Sense skin Lymph nodes耳鼻扁桃体Ears Nose Tonsils心肺腹部Heart Lungs Abdomen脊柱四肢神经系统system Spine Extremities Nervous其它所见Other abnormal finding胸部X线心电图检查Chest X-ray E C Gexam.化验室检查包括血清学诊断Laboratoryexam.(Serodiagnosis)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.Disease性病 Venereal 霍乱 Cholerafever开放性肺结核Opening lung tuberculosis 黄热病 Yellow艾滋病 AIDS 鼠疫 Plague精神病 Psychosis 麻风 Leprosy意见检查单位盖章StampOfficial Suggestion医师签字日期DatePhysicianofSignature。

外国人体格检查记录

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
胸部X线
检查结果
(附检查报告单）
Chest X-ray exam
(attached chest X-ray report)
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 ect)
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肺结核Lung tuberculosis
鼠疫Plague艾滋病AIDS
麻风Leprosy精神病Psychosis
意见：检查单位盖章
SuggestionOfficial stamp
医师签字日期
Signature of physician Date
感谢下载！！！
精神错乱Mental confusion…………………………………………………………………□No□Yes
精神病Psychosis；躁狂型Manic Psychosis……………………………………………□No□Yes

外国人体格检查记录

外国人体格检查记录Physical Examination Record for Foreigner姓名性别□男Male 出生日期Name Sex □女Female Birth Day-Month-Year照现在通讯地址血型Present Mailing Address Blood 片国籍出生地址typePhotoPlaceNationality Birth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 □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 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身高体重血压Height cm Weight kg Blood pressure mmHg发育情况营养情况颈部Development Nourishment Neck视力左L 矫正视力左L 眼右R EyesVision 右R Correctedvision辨色力皮肤淋巴结Colour Sense skin Lymph nodes耳鼻扁桃体Ears Nose Tonsils心肺腹部Heart Lungs Abdomen脊柱四肢神经系统system Spine Extremities Nervous其它所见Other abnormal finding胸部X线心电图检查Chest X-ray E C Gexam.化验室检查包括血清学诊断Laboratoryexam.(Serodiagnosis)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.Disease性病 Venereal 霍乱 Cholerafever开放性肺结核Opening lung tuberculosis 黄热病 Yellow艾滋病 AIDS 鼠疫 Plague精神病 Psychosis 麻风 Leprosy意见检查单位盖章StampOfficial Suggestion医师签字日期DatePhysicianofSignature。

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

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 PHYSICAL EXAMINATION RECORD FOR FOREIGNER

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 Cholera Venereal Disease 热 Yellow Fever
开放性肺结核 Opening lung tuberculosis Plague AIDS 风 Leprosy Psychosis
意见 Suggestion
检查单位盖章 Official Stamp
医师签字 Signature of physician
Date
Colour senห้องสมุดไป่ตู้e
Ears Heart
Nose Lungs
Tonsils Abdomen 神经系统
Spine 其它所见 Other abnormal findings
Extremities
Nervous system
X 线检查 Chest X-ray Exam
电图 ECG
化验室检查包括血清学诊断 Laboratory Exam Serodiagnosis
产褥期链球菌 Puerperal streptococcus infection
归热 Relapsing fever No Yes 伤寒和付伤寒 Typhoid and paratyphoid fever 流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis
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 or disorders endangering the pubic order and security? (Each item must be answered Yes or No ) 瘾 Toxic mania 精神错乱 Mental confusion Psychosis: Manic Psychosis No Yes No Yes 血压 Blood pressure 颈部 Neck L R Eyes 淋巴结 Lymph nodes mmHg Paranoid Psychosis 纪觉型 Hallucinatory Psychosis Height 发育情况 Development 视力 Vision L R Weight 营养情况 Nourishment 矫正视力 Corrected vision 皮肤 Skin No Yes No Yes No Yes

外国人体格检查记录

麻风Leprosy精神病Psychosis
意见：检查单位盖章
SuggestionOfficial stamp
医师签字日期
Signature of physician Date
斑疹伤寒Typhus fever □No□Yes 菌痢 □No□Yes
小儿麻痹症Polimyelitis □No□Yes 布氏杆菌病 □No□Yes
白喉Diphtheria □No□Yes 病毒性肝炎 □No□Yes
猩红热Scarlet fever □NO□Yes 产褥期链球 □No□Yes
None of the following diseases or disorders found during the present examination
霍乱Cholera性病Venereal Disease
黄热病Yellow fever肺结核Lung tuberculosis
鼠疫Plague艾滋病AIDS
外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
姓名
Name
性别
Sex
□男Male
□女Female
出生日期
Birth Day-Month-Year
照片
(加盖检查
单位印章)
(Photo stampห้องสมุดไป่ตู้d
Official stamped)
现在通讯地址
Present mailing address
胸部X线
检查结果
(附检查报告单）
Chest X-ray exam
(attached chest X-ray report)
心电图

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

FOREIGNER PHYSICAL EXAMINATION FORM

妄想型 Paranoid psychosis………………………………□No □Yes
幻觉型 Hallucinatory……………………………………□No □Yes
身高 Height
厘米 CM
体重 Weight
公斤 Kg
血压 Blood pressure
毫米汞柱 mmHg
发育情况 Development
(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
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)
Bacillary dysentery □No □Yes
Brucellosis Viral hepatitis
□No □Yes □No □Yes
Puerperal streptococcus infection
□No □Yes

外国人体格检查记录

Present mailing address
血型
Blood type
国籍
Nationality
出生地址
Birth Place
过去是否患有下列疾病（每项后面请回答“是”或“否”表示）
Have you ever had any of the following diseases?
(Each item must be answered “Yes” or “No”)
Signature of physician
检查单位盖章
Official stamp
日期
Date
□No□Yes
□No□Yes
□No□Yes
□No□Yes
产褥期链球菌感染Puerperal streptococcus infection
伤寒和付伤寒Typhoid and paratyphoid fever
流行性脑脊髓膜炎Epidemic cerebrospinal meningitis
□No□Yes
斑疹伤寒Typhus fever
小儿麻痹症Poliomyelitis
白喉Diphtheria
猩红热Scarlet fever
□No□Yes
□No□Yes
□No□Yes
□No□Yes
痢疾Bacillary dysentery
布氏杆菌症Brucellosis
病毒性肝炎Viral hepatitis
回归热Relapsing fever
左L
矫正视力
Corrected vision
左L
眼
Eyes
右R
右R
辨色力
Colour sense
皮肤Skin淋源自结Lymph nodes耳

外国人体格检查表FOREIGNERPHYS

外国人体格检查记录

外 国 人 体 格 检 查 记 录

外国人体格检查记录

PHYSICAL EXAMINATION RECORD FOR FOREIGNERS

外国人体检表

外国人体格检查表-中华人民共和国外交部

外国人体格检查记录 PHYSICAL EXAMINATION RECORD FOR FOREIGNER

外国人体格检查记录

上海外国语大学 外国人体格检查记录表

外国人体格检查表.docx

FOREIGNER PHYSICAL EXAMINATION FORM

外国人体格检查记录

外国人体格检查记录

上海外国语大学外国人体格检查记录表