外國人體格檢查表

1、附件 6外 國 人 體 格檢查表FOREIGNER PHYSICAL EXAMINATION FORM姓名Name性別Sex男 Male女 Female出生日期Birth Day Month - Year照 片現(xiàn)在通信地址Present mailing address 血型(加蓋檢查單位印章 )國籍或地區(qū)Nationality (or Area)出生地址Birth PlaceBlood type Photo(stampedOfficial stamp)過去是否患有下列疾?。?（每項后面請回答“否”或“是” ）Have you ever had any of the following dese

2、ases?(Each item must be answered “Yes”or “No ”)斑 疹傷寒 Typhus fever N o Yes 菌 痢 Bacillary dysentery NoYes小兒麻痹癥 Poliomyelitis N o Yes 布氏桿菌病 Brucellosis NoYes白 喉 Diphtheria N o Yes 病毒性肝炎 Viral hepatitis NoYes猩紅熱Scarlet fever N o Yes產(chǎn)褥期鏈球 Puerperal streptococcus infection回歸熱Relapsing fever N o Yes 菌 感 染

3、NoYes傷寒和付傷寒 Typhoid and paratyphoid fever NoYes流行性腦脊髓膜炎 Epidemic cerebrospinal meningitis No Yes是否患有下列危機公共秩序和安全的病癥： （每項后面請回答“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”of “No”)毒物癮Toxicomania NoYes精神錯亂 Met

4、al confusion NoYes精神病 Psychosis：躁狂型 Manic Paychosis NoYes妄想型 Paranoid psychosis NoYes幻想型 Hallucinatory psychosis NoYes 體重 公斤 血壓毫米汞柱身高 厘米Height CM Weight kg Blood pressure mmHg 營養(yǎng)情況頸部發(fā)育情況Development Nourishment Neck 視力 左 L_矯正視力 左 L_眼Vision 右 R Corrected vision 右 R Eyes辨色力 皮膚 淋巴結(jié)Colour senses Skin Lym

5、ph nodes耳 鼻 扁桃體Ears Nose Tonsils心 肺 腹部Heart Lungs Abdomen脊 柱 四 肢 神經(jīng)系統(tǒng)Spine Extremities Nervous system其它所見Other abnormal findings胸部 X 線檢查結(jié)果（附檢查報告單）心電圖Chest X-rayECG Exam(attached chest X-rayreport)化驗室檢查（包括艾滋病、梅毒等血清學檢查）Laboratory exam (Attached testreport of AIDS,Syphilis etc)未發(fā)現(xiàn)患有下列檢疫傳染病和危害公共健康的疾?。篘o

6、ne of the following diseases of disorders found during the present examination.霍 亂 Cholera 性 病 Venereal Disease黃熱病 Yellow fever 肺結(jié)核 Lung tuberculosis鼠 疫 Plague 艾滋病 AIDS麻風Leprosy 精神病 Psychosis意見檢查單位蓋章Suggestion Official Stamp醫(yī)師簽字 日期Signature of physician DateThe foreigners are supposed to take the ph

7、ysical examination before leaving in a national or regional public hospital andget report of all the items listed in the form with the signature of the doctor and the stamp of the hospital. If the check isdone in a private hospital or clinic, the report should be notarized by a public notary. The fo

8、rm submitted should be theoriginal copy with the photo of the examinee and supporting documentations such as laboratory report sheets,X-ray films and necessary testing reports.The Administration of Quality supervision, Inspection and Quarantine will double check the submitted form and attacheddocumentations upon their arrival and decide whether it's acceptable or they should take additional or another physicalexamination. If additional check or re-check is required, the student should