广东省国际旅行卫生保健中心出入境人员健康检查申请表

出入境人员健康检查申请表 HEALTH EXAMINATION APPLICATION FORM FOR PERSONS OF ENTRY-EXIT
姓名 Name： 国籍 Nationality： 电话 Tel No.： 文化程度 Education： 现单位 Company： 现住详细地址 Present Address： 病史问卷 Medical History Questionaire (在医生指导下完成 Answer the following questions under the guidance of a 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 “是”，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 answer“Yes ”in the relative disease and specify to the doctor. 斑 疹 伤 寒 Typhoid fever 布氏杆菌病 Brucellosis 猩红热 Scarlet fever 精神病： Psychosis： 躁狂型 Manic 妄想型 Paranoid 幻觉型 Hallucinatory 产褥期链球菌感染 Puerperal streptococcus infection 已生育女性填写 For the bore women □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes 菌痢 Bacillary dysentery 白喉 Diphtheria 伤寒和副伤寒 Typhoid and paratyphoid fever 毒物瘾 Toxicomania 回归热 Relapsing fever 疟疾 Malaria 流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes 小儿麻痹症 Poliomyelitis 病毒性肝炎 Virus hepatitis 精神错乱 Mental confusion 艾滋病 AIDS 性病 Venereal Disease 结核 Tuberculosis 其他传染病 Other infections disease □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes □是 Yes
法定检查项目(Required Tests): □身高、体重、血压、体温、内外科、五官科、心电图、超声检查（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） ，尿常规、血常规等 。 Height, Weight, Blood Pressure, Temperature, Internal Medicine, ENT, EKG, Ultrasonography (liver, gallbladder, spleen and kidneys), Chest X-ray, Blood Test(Blood Type ,ALT ,HBsAg , Anti-HIV, TPPA for syphilis, Anti-HCV), Urinalysis and Routine Blood test, etc. □验证 Confirmation procedure □验血（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、血常规） Blood Test(Blood Type ,ALT ,HBsAg , Anti-HIV, TPPA for syphilis, Anti-HCV and Routine Blood test) . □超声检查（肝胆脾、双肾） Ultrasonography (liver, gallbladder, spleen and kidneys) 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 confirmed that my personal information is correct. I understand what is to be done during the examination and agree to have the examination which is mentioned above. 签名 Signature: 备注 Note： 审核医生签名 Doctor signature： 日期: 年 月 日. Date： 日期: 年 月 日. Date：
职业 Occupation： 性别 Gender: □男 Male □女 Female □未婚 Single
婚姻on：
最近 7 天内您是否有发热和咳嗽？ Have you had a fever or cough within the last 7days? □是 Yes 如您有病史（包括过去及现患病） ，且需要让医生知道的，请在空白处填写并向医生申明。 If you had past or present medical history that we should know, please fill in the blanks: 如果未患上述疾病或症状，请回答： Did you have the diseases or symptoms which were mentioned above? 如果曾/现患有上述疾病或症状，请详细说明： If you had the diseases or symptoms which were mentioned above, please specify: □ 否 □ No