外国人体检表图文稿
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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
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
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
Doyouhaveany ofthefollowingdiseasesordisordersendangeringthepublicorderand security? (Eachitemmustbeanswered“Yes”or“No”)
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.
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.
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
境外人员体格检查记录
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：
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
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
外国人体格检查表
□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
Corrected Vision 右 R
眼
Eyes
辩色力
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
Birth Day-Month-Year
照片
（加盖检查单位印章）
Photo
(Stamped Official Stamp)
现在通讯地址
Present mailing address
□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 following diseases or disorders endangering the public order and security?
(Each item must be answered “Yes” or “No”)
Colour sense
皮肤
Skin
淋巴结
Lymph nodes
耳
Ears
鼻
Nose
扁桃体
Tonsils
心
Heart
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
辩色力
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
Birth Day-Month-Year
照片
（加盖检查单位印章）
Photo
(Stamped Official Stamp)
现在通讯地址
Present mailing address
□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 following diseases or disorders endangering the public order and security?
(Each item must be answered “Yes” or “No”)
Colour sense
皮肤
Skin
淋巴结
Lymph nodes
耳
Ears
鼻
Nose
扁桃体
Tonsils
心
Heart
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.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
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斑疹伤寒Typhus fever细菌性痢疾Bacillary dysentery
小儿麻痹症Poliomyelitis布氏杆菌病Brucellosis
白 喉 Diphtheria 病毒性肝炎 Viral hepatitis
猩红热Scarlet fever产褥期链球菌 Puerperal streptococcus
皮肤/Skin
淋巴结/Lymph nodes
耳/Ears
鼻/Nose
பைடு நூலகம்扁桃体/Tonsils
心/Heart
肺/Lungs
腹部/Abdomen
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
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
Signature of physician Date
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
出生日期____年___月___日
Date of Birth y.___m.___d.___
照片
Photo
(Put ospital
seal across the photo)
精神病Psychosis：躁狂型Manic psychosis ·······························
妄想型Paranoid psychosis ······························
幻觉型Hallucinatory psychosis ··························
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
现在通迅地址
Present mailing adderss
血型
Blood Type
国籍
Natio-
nality
出生地
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 diseases(
Each ietm must be answered“Yes”or“No”
回归热Relapsing fever感 染 Infection
伤寒和副伤寒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 diseases or disorders endangering the public order and secure?
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 Yholera 性 病 Venereal Disease
黄热病 Yellow fever 开放性肺结核 Opening lung tuberculosis
心电图/ECG
化验室检查(包括艾滋病、梅毒血清学诊断)/
Laboratory Exam(HIV, Syphilis Serodiagnosis)
附上对以下项目的化验室报告：Please attach the results and data sheets for the following items:AIDS.,Syphilis,ALT.,AST.,T-BIL.,and HbsAG.
(Each item most be answered“Yes”or“No”)
毒物瘾Toxicomania····················································
精神错乱Mental confusion ···············································
小儿麻痹症Poliomyelitis布氏杆菌病Brucellosis
白 喉 Diphtheria 病毒性肝炎 Viral hepatitis
猩红热Scarlet fever产褥期链球菌 Puerperal streptococcus
皮肤/Skin
淋巴结/Lymph nodes
耳/Ears
鼻/Nose
பைடு நூலகம்扁桃体/Tonsils
心/Heart
肺/Lungs
腹部/Abdomen
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
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
Signature of physician Date
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
出生日期____年___月___日
Date of Birth y.___m.___d.___
照片
Photo
(Put ospital
seal across the photo)
精神病Psychosis：躁狂型Manic psychosis ·······························
妄想型Paranoid psychosis ······························
幻觉型Hallucinatory psychosis ··························
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
现在通迅地址
Present mailing adderss
血型
Blood Type
国籍
Natio-
nality
出生地
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 diseases(
Each ietm must be answered“Yes”or“No”
回归热Relapsing fever感 染 Infection
伤寒和副伤寒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 diseases or disorders endangering the public order and secure?
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 Yholera 性 病 Venereal Disease
黄热病 Yellow fever 开放性肺结核 Opening lung tuberculosis
心电图/ECG
化验室检查(包括艾滋病、梅毒血清学诊断)/
Laboratory Exam(HIV, Syphilis Serodiagnosis)
附上对以下项目的化验室报告：Please attach the results and data sheets for the following items:AIDS.,Syphilis,ALT.,AST.,T-BIL.,and HbsAG.
(Each item most be answered“Yes”or“No”)
毒物瘾Toxicomania····················································
精神错乱Mental confusion ···············································