1/2外国人体格检查表PHYSICALEXAMINATIONRECORDFORFOREIGNERS姓名Name性别Sex□男Male□女Female出生日期Dateofbirth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”）Haveyoueverhadanyofthefollowingdisease?（Eachitemmustbeanswered“Yes”or“No”）斑疹伤寒Typhusfever□No□Yes菌痢Bacillarydysentery□No□Yes小儿麻痹症Poliomyelitis□No□Yes布氏杆菌Brucellosis□No□Yes白喉Diphtheria□No□Yes病毒性肝炎Viralhepatitis□No□Yes猩红热Scarletfever□No□Yes产褥期链球菌Puerperalstreptococcusinfection回归热Relapsingfever□No□Yes□No□Yes伤寒和副伤寒Typhoidandparatyphoidfever□No□Yes流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□No□Yes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”）Doyouhaveanyofthefollowingdiseaseordisordersendangeringthepublicorderandsecurity?（Eachitemmustbeanswered“Yes”or“No”）毒物瘾Toxicomania-------------------------------------------------------------------------------□No□Yes精神错乱Mentalconfusion---------------------------------------------□No□Yes精神病Psychosis：狂躁型Manicpsychosis-------------------------------------------------□No□Yes妄想型Paranoidpsychosis-------------------------------------------□No□Yes幻觉型Hallucinatorypsychosis-----------------------□No□Yes身高Heightcm体重Weight血压Bloodpressure发育情况Development营养状况Nourishment颈部Nest视力左LVision右R矫正视力左LCorrectedvision右R眼E辨色力Colorsense皮肤Skin淋巴结Lymphnods耳Ears鼻Nose扁桃体Tonsils心Heart肺Lungs腹部Abdomen脊柱Spine四肢Extremities神经系统Nervoussystem其他所见Otherabnormalfindings2/2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）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Cholera性病Venereal黄热病Yellowfever开放性肺结核Openinglungtuberculosis鼠疫Plague爱滋病AIDS麻风Leprosy精神病Psychosis意见检查单位盖章SuggestionOfficialStamp医师签字日期SignatureofphysicianDate
