出入境人员健康检查申请表 HEALTH EXAMINATION REGISTRATION...

签名Signature:
推荐检查项目(Recommended Tests):
□乙肝四项（乙肝表面抗体、乙肝e抗原、乙肝e抗体、乙肝核心抗体）□甲肝抗体二项。□生化12项（肝功能：谷草转氨酶、谷氨酰转肽酶、总蛋白、白蛋白、球蛋白、白/球。血脂：总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇。肾功能：血尿素氮、血肌酐。其它：血尿酸、血糖），□甲胎蛋白(肝癌检查)癌胚抗原（肠癌检查）□EB病毒（鼻咽癌筛查）。□B超检查:男性前列腺。□骨密度检测。□粪便培养。□粪便常规。□乙肝表面抗体（定量、定性）。□乙肝病毒基因检测。□PPD试验。
斑疹伤寒Typhoid fever
□有Yes
菌痢Bacillary dysentery
□有Yes
小儿麻痹症Poliomyelitis
□有Yes
布氏杆菌病Brucellosis
□有Yes
白喉Diphtheria
□有Yes
病毒性肝炎Virus hepatitis
□有Yes
猩红热Scarlet fever
备注：
审核医生签名：日期:年月日.date：
□有Yes
回归热Relapsing fever
□有Yes
精神错乱Mental confusion
□有Yes
精神病：躁狂型Manic
Psychosis：妄想型Paranoid
幻觉型Hallucinatory
□有Yes
毒物瘾Toxicomania
□有Yes
艾滋病AIDS
□有Yes
□有Yes
伤寒和副伤寒Typhoid and paratyphoid fever
□其他：Other:
□妇科:□B超检查子宫及附件。□.电脑乳腺红外线检查。□妇女内外生殖器官检查+电脑辅助细胞学筛查(宫颈癌检查)。
Gynecological examination:□B-ultrasonic examination forWomb and Appendage.□Computer Diaphanography Imaging.□Edeoscopy and Secretion routine ,Cervical exfoliative cytoliative examinationby computer assistant(Examination for Cervical carcinoma.)
□有Yes
性病Venereal Disease
□有Yes
□有Yes
疟疾Malaria
□有Yes
结核Tuberculosis
□有Yes
产褥期链球菌感染（已生育女性填写）Puerperal streptococcusinfection（For the bore women）
□有Yes
流行性脑脊髓膜炎Epidemic cerebrospinal meningitis
如果没有患有上述疾病或症状，请回答：□没有
Ifnever have or had any diseases or symptoms which mentioned above, pleaseanswer：□No
如果曾/现患有上述疾病或症状，请详细说明：Ifhave or had any diseases or symptoms which mentioned above, please specify:
出入境人员健康检查申请表HEALTH EXAMINATION REGISTRATION FROM FOR THE PERSONS OF ENTRY-EXIT
姓名Name
职业Occupation
已婚Married
□是Yes□否No
文化程度Education
电话Tel No.
前往国家Destination
我已知道推荐的体检内容，同意进行上述检查。I understand what is recommendedand agree to get the examinationwhichismentioned above.
签名:signature:
□外文翻译份□X光报告、携带X光片□HIV报告□签发其它检查检验报告□验证□验血□B超检查（肝、胆、脾、双肾）
签证必须检查项目(Required Testsfor visa):
身高、体重、血压、体温、内外科、五官科、心电图、B超（肝胆脾、双肾）、X光胸片、血液检测（血型、谷丙转氨酶、乙肝表面抗原、艾滋病抗体、梅毒抗体、丙肝抗体），尿分析、血常规等。Height, Weight, Blood Pressure, Temperature, Internal Medicine, ENT, EKG,B-ultrasound,(liver, gallbladder, spleen and kidneys), Chest X-ray, Blood Test(Blood Type, ALT, HBsAg，HIV, TPPA（or TRUST）, Anti-HCV), Urinalysisand Blood Routine，etc。
本人申明以上提供的资料真实，已核对个人资料无误，并已知道体检内容，同意进行体检。
I declare that the information I have provided above is true to the best of my knowledge and I have checked that my personal information is correct and I understand what is to be done during the examination and agree to have the examination which is mentioned above.
□有Yes
其他传染病Other infections disease
□有Yes
最近7天内您是否有发热和咳嗽？□有Have you hadafeverorcough within the last 7days?□Yes
是否现患或曾患有其他疾病史？□有Haveor hadyouever hadany otherdiseases？□Yes
现单位Present WorkingCompany
现地址story Questionaire(在医生指导下完成answer the following questions in the presence of the doctor)
过去是否患有下列疾病或危及公共秩序和安全的病症：如有请在下列相应疾病栏回答有，并详细说明。Have you ever had any of the following diseases or disorders endangering the public order and security?If you have or ever had ,Please answerYes in the relative disease and specify.
□Test for Hepatitis B( HBsAb,HBeAg,HBeAb,HBcAb).□HBsAb（Quantitative、Qualitative）□Test for Hepatitis A(HAV-IgM,HAV-IgG).
□Biochemical test:（Test forLiver function: AST, r-PT, T.Prot，ALB, GLOB, A/G. Test for Blood-Lipid: CHOL,TG,HDL-C,LDL-C. Test forKidney function: BUN, Creatinine.Other:UA, GLU.）.□AFP（Testfor Hepatic carcinoma）.CEA(TestforIntestinalCarcinoma)□VCA-IgA（Screening test for Nasopharyngeal Carcinoma）.□B-ultrasonic examination for Prostate(Male).□Examination for a bone densitometry.□Feces culture.□FecesRoutine.□HBsAb（Quantitative、Qualitative）.□HBV-DNA.□PPD test.