1/2外国人体格检查记录PhysicalExaminationRecordforForeigner姓名Name性别Sex□男Male□女Female出生日期BirthDay-Month-Year照片Photo现在通讯地址PresentMailingAddress血型Bloodtype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“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”）Doyouhaveanyofthefollowingdiseasesordisordersendangeringthepublicorderandsecurity？（Eachitemmustbeanswered“Yes”or“No”）身高Heightcm体重Weightkg血压BloodpressuremmHg发育情况Development营养情况Nourishment颈部Neck视力左LVision右R矫正视力左LCorrectedvision右R眼Eyes辨色力ColourSense皮肤Skin淋巴结Lymphnodes耳Ears鼻Nose扁桃体Tonsils心Heart肺Lungs腹部Abdomen斑疹伤寒小儿麻痹症白喉猩红热回归热TyphusfeverPoliomyelitisDiphtheriaScarletfeverRelapsingfever□No□Yes□No□Yes□No□Yes□No□Yes□No□Yes菌痢Bacillarydysentery布氏杆菌病Brucellosis病毒性肝炎Viralhepatitis产褥期链球菌感染Puerperalstreptococcusinfection□No□Yes□No□Yes□No□Yes□No□Yes毒物瘾Toxicomania．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．精神错乱Mentalconfusion．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．精神病Psychosis:躁狂型ManicPsychosis．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．妄想型ParanoidPsychosis．．．．．．．．．．．．．．．．．．．．．．．．．．．．幻觉型HallucinatoryPsychosis．．．．．．．．．．．．．．．．．．．．．．．．．□No□Yes□No□Yes□No□Yes□No□Yes□No□Yes伤寒和副伤寒Typhoidandparatyphoidfever流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□No□Yes□No□Yes2/2脊柱Spine四肢Extremities神经系统Nervoussystem其它所见Otherabnormalfindings胸部X线检查ChestX-rayExam.心电图ECG化验室检查包括血清学诊断LaboratoryExam.(Serodiagnosis)是否发现患有下列检疫传染病和危害公共健康的疾病:Doyouhaveanyofthefollowingdiseasesordisordersfoundduringthepresentexamination?（Eachitemmustbeanswered“Yes”or“No”）意见检查单位盖章SuggestionOfficialStamp医师签字日期SignatureofPhysicianDate霍乱黄热病鼠疫麻风性病开放性肺结核艾滋病精神病Cholera□No□YesYellowfever□No□YesPlague□No□YesLeprosy□No□YesVenerealDisease□No□YesOpeninglungtuberculosis□No□YesAIDS□No□YesPsychosis□No□Yes
