附录 2：《外国人体格检查记录》表
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。
外国人体检表
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
姓名
Name
性别男Male
Sex女Female
出生日期____年___月___日
Date of Birth y.___m.___d.___
照片
Photo
(Put ospital
seal across the photo)
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Development
营养情况Nourishment
颈部Neck
视力
Vision
左L
右R
矫正视力
Corrected
vision
左L
右R
眼Eyes
辨色力/Color sense
(Each item most be answered “Yes” or “No”)
毒物瘾Toxicomania····················································
精神错乱Mental confusion···············································
现在通迅地址
Present mailing adderss
血型
Blood Type
国籍
Natio-
nality出生地B NhomakorabearthPlace
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 ietm must be answered “Yes”or “No”
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 范本.docx
毒物瘾Toxicomania…………………………………………………□No□Yes
精神错乱Mental confusion……………………………………………□No□Yes
精神病Psychosis：躁狂型Manicpaychosis…………………………………□No□Yes
妄想型Paranoid psychosis………………………………□No□Yes
幻觉型Hallucinatory……………………………………□No□Yes
外国人体格检查表
FOREIGNERPHYSICALEXAMINATIONFORM
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
Presentmailingaddress
国籍或地区Nationality (orArea)
心电图ECC
化验室检查(包括艾滋病、梅毒等血清学检查)
Laboratoryexam(attachedtestreportof 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:
Noneofthefollowing diseasesofdisordersfound duringthe present examination.
境外人员体格检查记录
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：
None of the following diseases or disorders found during the present examination
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
Corrected Vision右R
眼
Eyes
辨色力
Colour sense
皮肤
Skin
淋巴结
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共秩序和安全的病症：(每项后面请回答“是”或“否”)
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”)
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
外国人体格检查记录
丙氨酸氨基转移酶ALT(GPT)
血常规Blood Routine
白细胞总数WBC
红细胞总数RBC
血小板总数PLT
血红蛋白HGB
粒细胞百分比NEUT%
淋巴细胞百分比LYM%
尿常规Urine Routine
葡萄糖GLU
蛋白质PRO
红细胞ERY
白细胞LEU
其它Others
血清葡萄糖GLU
心脏
Heart
腹部
Abdomen
脊柱和四肢
Spine&Extremities
神经精神系统
Neuropsychiatric System
泌尿生殖系统
Genitournary System
视力左L
Vision右R
矫正视力左右
Corrected vision L R
辨色力
Color sense
听力左右
Hearing Left Right
眼、耳、鼻、喉
Eyes,Ears,Nose,Throat
心电图
ECG
腹部超声（肝胆脾肾）
Abdomen Ultrasound(Liver,Gallbladder,Spleen,Kidney)
胸部X线
Chest X-ray
艾滋病病毒抗体Anti-HIV
梅毒血清学检测Syphilis Serology
乙型肝炎表面抗原HBsAg
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 DaymonthYear
外国人体格检查记录
外国人体格检查记录日期：20xx年xx月xx日受检者信息：姓名：John Smith性别：男国籍：美国年龄：30岁身高：180厘米体重：80公斤检查目的：本次体格检查旨在评估受检者的身体状态，并提供给他参加工作或定居的相关证明。
体格检查记录：一、一般信息受检者John Smith身体健康并具备良好的体格状况。
他表现出对体格检查的积极配合，并对各项检查项目进行了详细回答。
二、病史1.既往病史：受检者没有重大的既往病史。
没有患有传染性疾病、恶性肿瘤、心脏病、精神疾病等。
2.过敏史：受检者没有任何过敏史，包括对药物、食物等过敏反应。
三、生命体征1.血压：受检者血压正常，收缩压为120mmHg，舒张压为80mmHg。
2.体温：受检者体温正常，为36.8摄氏度。
3.脉搏：受检者心率规律，脉搏为每分钟80次。
4.呼吸：受检者呼吸平稳，每分钟16次。
四、身体系统检查1.头颈部：头颅外形正常，无明显外伤痕迹。
颈部无肿大淋巴结。
眼结膜粉红，无黄疸。
口腔黏膜正常，无溃疡或出血病灶。
耳、鼻、喉无异常。
2.胸部：胸廓对称，无畸形。
双肺呼吸音清晰，无啰音。
心脏听诊无异常，心率齐。
3.腹部：腹壁平坦，无压痛。
肝脏、脾脏未触及，无包块。
肠鸣音正常。
4.四肢：四肢无肿胀、变形或关节畸形。
上下肢力量正常，活动自如。
皮肤无异常。
5.神经系统：受检者神经系统正常，生理反射活跃，无异常感觉或运动障碍。
五、辅助检查1.血液检查：血液常规检查结果在正常范围内，红细胞、白细胞、血小板计数正常。
2.尿液检查：尿液检查未发现异常，无蛋白质、血红蛋白、尿糖等异常成分。
六、结论与建议根据以上检查结果，受检者John Smith身体健康且符合工作或定居的相关要求。
建议受检者继续保持良好的生活习惯，遵循健康饮食、定期锻炼，以保持身体健康。
此检查记录可用于提供给相关机构，作为受检者工作或定居的证明。
本次体格检查报告共计1200字，记录了受检者John Smith的一般信息、病史、生命体征、身体系统检查、辅助检查等内容。
外国人体格检查记录
（附检查报告单）
Chest X-ray Exam
(attached chest X-ray report)
心电图
ECG
化验室检查
（包括爱滋病、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Байду номын сангаас公共健康的疾病
（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：燥狂型Manic psychosis□No□Yes
妄想型Paranoid psychosis□No□Yes
麻风Leprosy精神病Psychosis
意见检查单位盖章
Suggestion Official Stamp
医师签字日期
Signature of physician Date
幻觉型Hallucinatory psychosis□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左R
矫正视力左L
Corrected vision左R
血型
Blood Type
过去是否患有下列疾病：（每项后面请回签“否”或“是”）
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
外国人体格检查表
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”)
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
The foreigners are supposed to take the physical examination before leaving in a national or regional public hospital and get report of all the items listed in the form with the signature of the doctor and the stamp of the hospital. If the check is done in a private hospital or clinic, the report should be notarized by a public notary.The form submitted should be the original copy with the photo of the examinee and supporting documentations such as laboratory report sheets, X-ray films and necessary testing reports.
外国人体格检查记录
外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNR外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER体检说明EXPLANATION OF THE PHYSICAL EXAMINATION1．在华学习六个月以上的外国留学生，应按照“外国人体格检查记录”进行体格检查。
体检表贴照片处，应有医院印章，否则，视体检表无效。
Ⅰ．The foreign students, who intend to study in China for more than 6 months, should go through a physical check-up before they come to China, according to the requirements of Physical Examination Record for Foreigners. The hospital seal should be put across the photo on the Examination Record, or the Record is invalid.2．体检表应填写清楚，体检报告应附有X光透视胸片及霍乱、黄热、鼠疫、麻风、性病、开放性肺结核、艾滋病、肝功能、澳抗和精神病的化验室检查报告。
外国留学生和专家到天津外国语学院报到时，我们将体检表及化验室检查报告送至天津市卫生检疫局查验。
凡体检查验不合格者，需在天津市卫生检疫局重新体检，费用自理。
Ⅱ．All the items of this form should be filled in carefully and clearly. The report should be attached with the negative film for Chest X-ray exams, and the examination certificates for laboratory exams (Serodiagnosis), which include exams on Cholera, Yellow fever, Plague, Leprosy, Venereal Disease, Opening lung tuberculosis, AIDS, Psychosis, Liver function and HB&AG. On their arrival at Tianjin Foreign Studies University , the Record (a original copy) and laboratory exam certificates should be sent to Tianjin Quarantine Bureau for check. Those whose exam are not qualified should get the physical re-check up done in Tianjin . The expenses should be covered by themselves.3.体检应在来华一个月前在公立医院进行，凡在私立医院体检者，应取得公证部门的公证。
外国人体格检查表FOREIGNERPHYS
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
其它所见
Other abnormal findinest X-ray
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
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
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
外国人体格检查记录
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
附录2《外国人体格检查记录》表
左L
右R
矫正视力
Corrected vision
左L
右R
眼Eyes
辨色力/Color sense
皮肤/Skin
淋巴结/Lymph nodes
耳/Eห้องสมุดไป่ตู้rs
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
Ⅰ．The foreign students, who intend to study inChinafor 6 months or more, should go through a physical check-up before they come toChina, according to the requirements of Physical Examination Record for Foreigners. The hospital seal should be put across the photo on the Examination Record, or the Record is invalid.
4.体检表是办理入境签证及在华居留手续所需文件之一，留学生到达浙江旅游职业学院报到时，应提交正本。
Ⅳ.The Physical Examination Form is one of the documents that is needed in the process of going through the visa formalities. The students should bring the original copy along with them when they come toTourismCollegeofZhejiang.
外国人体格检查记录
外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER体检说明EXPLANATION OF THE PHYSICAL EXAMINATION1．在华学习外国留学生，应按照“外国人体格检查记录”进行体格检查。
体检表贴照片处，应有医院印章，否则，视体检表无效。
Ⅰ．The foreign students, who study in China, should go through a physical check-up before they come to China, according to the requirements of Physical Examination Record for Foreigners. The hospital seal should be put across the photo on the Examination Record, or the Record is invalid.2．体检表应填写清楚，体检报告应附有X光透视胸片及霍乱、黄热、鼠疫、麻风、性病、开放性肺结核、艾滋病、肝功能、澳抗和精神病的化验室检查报告。
Ⅱ．All the items of this form should be filled in carefully and clearly. The report should be attached with the negative film for Chest X-ray exams, and the examination certificates for laboratory exams (Serodiagnosis), which include exams on Cholera, Yellow fever, Plague, Leprosy, Venereal Disease, Opening lung tuberculosis, AIDS, Psychosis, Liver function and HBsAG.3.体检报告应在在线填写报名表时提交体检报告。
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外国人体格检查记录
外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
体检说明
EXPLANATION OF THE PHYSICAL EXAMINATION
1．在华学习六个月以上的外国留学生，应按照“外国人体格检查记录”进行体格检查。
体检表贴照片处，应有医院印章，否则，视体检表无效。
Ⅰ．The foreign students, who intend to study in China for 6 months or more, should go through a physical check-up before they come to China, according to the requirements of Physical Examination Record for Foreigners. The hospital seal should be put across the photo on the Examination Record, or the Record is invalid.
2．体检表应填写清楚，体检报告应附有X光透视胸片及霍乱、黄热、鼠疫、麻风、性病、开放性肺结核、艾滋病、肝功能、澳抗和精神病的化验室检查报告。
外国留学生到浙江旅游职业学院报到时，我们将体检表及化验室检查报告送至浙江省卫生检疫局查验。
凡体检查验不合格者，需在杭州市卫生检疫局重新体检，费用自理。
Ⅱ．All the items of this form should be filled in carefully and clearly. The report should be attached with the negative film for Chest X-ray exams, and the examination certificates for laboratory exams (Serodiagnosis), which include exams on Cholera, Yellow fever, Plague, Leprosy, Venereal Disease, Opening lung tuberculosis, AIDS, Psychosis, Liver function and HB&AG. On their arrival at Tourism College of Zhejiang , the Record (a original copy) and laboratory exam certificates should be sent to Zhejiang Quarantine Bureau for check. Those whose exam are not qualified should get the physical re-check up done in Hangzhou . The expenses should be covered by themselves.
3.体检应在来华一个月前在公立医院进行，凡在私立医院体检者，应取得公证部门的公证。
到达浙江旅游职业学院报到时，体检时间不得超过六个月，否则应在杭州重新检体，费用自理。
Ⅲ.The physical examination should be taken in the public hospitals one month before their departure. If the physical check-up is done at a private hospital, the student should get the certificate notarized. If the physical check-up is over 6 months old on the day of their registration, they should have re-check up in Hangzhou . The expenses should be covered by themselves.
4.体检表是办理入境签证及在华居留手续所需文件之一，留学生到达浙江旅游职业学院报到时，应提交正本。
Ⅳ.The Physical Examination Form is one of the documents that is needed in the process of going through the visa formalities. The students should bring the original copy along with them when they come to Tourism College of Zhejiang.。