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1、外国人体格检查记录PHYSICA1.EXAMINATIONRECORDFORFOREIGNER姓名Name性别Sex男Male女Female出生日期BirthDate(Day-Month-Year)照片Photo现在通讯地址Presentmailingaddress血型BloodIyPe国籍Nationality出生地址BirthPlace过去是否患有下列疾病：(每项后面请回答否或是)Haveyoueverhadanyofthefollowingdiseases?(Eachitemmustbeanswered“Yesor“No)斑疹、伤寒TyphusfeverNoYes菌痢Bacillaryd
2、ysenteryNoYes小儿麻痹症PoliomyelitisNoYes布氏杆菌病BrakelessNoYes白喉DiphtheriaNoYes病毒性肝炎ViraIhepatitisNoYes猩红热ScarletfeverNoYes产褥期链球菌感染PuerperalstreptococcusInfectionNoYes回归热RelapsingfeverNoYes伤寒和副伤寒TyphoidandparatyphoidfeverNoYes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M)Doyouhaveanyofthefollowingdiseasesordisordersend
3、angeringthepublicorderandsecurity?(EachitemmustbeansweredYes”orNo”)毒物痛ToxicmaniaNoYes精神错乱MentalconfusionNoYes精神病Psychosis:躁狂型ManicpsychosisNoYs妄想型ParanoidpsychosisNoYes幻世型HallucinatoryDsvchosisNoYes身高厘米Heightcm体重公斤WeightKg血压毫米汞柱BloodpressuremmHg发育情况Development营养情况Nourishment颈部Neck视力左1.Vision右R矫正视力左1
4、.Correctedvision右R眼Eyes辨色力Colorsense皮肤Skin淋巴结1.ymphnodes耳Ears鼻Nose扁桃体Tonsils心Heart肺1.ungs腹部Abdomcn编号：42(1927cm)脊柱Spine四肢Extremities神经系统Nitroussystem其它所见Otherabnormalfindings胸部X线检查ChestX-rayexam.心电图ECG化验室检查包括艾滋病、梅毒血清学诊断1.aboratoryexam.(HIV,SyphilisSerodiagnosis)未发现患有下列检疫传染病和危害公共健康的疾病：Noneofthefollowingdiseasesordisordersfoundduringthepresentexamination.霍乱Choleras性病VenerealDisease黄热病Yellowfever开放性肺结核Openinglungtuberculosis鼠疫Plague艾滋病AIDS麻风1.eprosy精神病Psychosis意见检查单位盖章SuggestionOfHciaIStamp医师签字日期SignatureofphysicianDate
