外国人体格检查记录
PHYSICALEXAMINATIONRECORDFORFOREIGNER
验证证明
CERTIFICATEOFVERIFICATION
姓名Name_____________国籍Natio
ality_________发证日期IssuedDate__________
性别Sex______________________出生日期DateofBirth______________护照号码PassportNumber_____________
现在通信地址Prese
tAddress_________________________________________
兹证明上列人员所持外国人体格检查记录经过验证符合要求。兹证明上列人员所持外国人体格检查记录经过验证符合要求。
Thisistocertifythatthebearer’sPhysicalExami
atio
RecordforForeig
eraccordwiththerequireme
t
医师签字
Sig
atureofPhysicia
_____________________
验证单位盖章
Officialstamp
日期Date_______________________________
f外国人体格检查记录PHYSICIALEXAMINATIONRECORDFORFOREIGNER
姓名性别男□Male出生日期BirthDayMo
thYearNameSex女□Female照片现在通讯地址血型Prese
tMaili
gAddressBloodPhotoType国籍出生地址Natio
alityBirthPlace过去是否患有下列疾病（每项后面请回答“否”或“是”）Haveyoueverhada
yofthefollowi
gdiseasesEachitemmustbea
swered“yes”or“
o”斑疹伤寒Typhusfever□No□Yes菌痢Bacillarydyse
tery□Yes□No小儿麻痹症Poliomyelitis□No□Yes布氏杆菌病Brucellosis□Yes□No白喉Diphtheria□No□Yes病毒性肝炎Vitalhepatitis□Yes□No猩红热Scarletfever□No□Yes产褥期链球菌感染PuerperalStreptococcusI
fectio
□No□Yes回归热Relapsi
gfever□No□Yes伤寒和副伤寒Typhoida
dparatyphoidfever□Yes□No流行性脑脊髓膜炎Epidemiccerebrospi
alme
i
gitis□Yes□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”）Doyouhavea
yofthefollowi
gdiseasesordisorderse
da
geri
gthepublicordera
dsecurityEachitemmustbea
swered“Yes”or“No”毒物瘾精神错乱精神病Toxicoma
ia…………………………………□Yes□NoMe
talco
fusio
……………………………□Yes□NoPsychosis，躁狂型Ma
icpsychosis…………□Yes□No妄想型Para
oidpsychosis………□Yes□No幻觉型Halluci
atorypsychosis…□Yes□Nocm体重Weight营养情况Nourishme
t矫正视力左L_________Correctedvisio
右R皮肤Ski
鼻Nose肺Lo
gkg血压Bloodpressure颈部Neck眼Eye淋巴结Lymph
odes扁桃体To
sils腹部Abdome
mmHg
身高Height发育情况Developme
t视力Visio

左L______________右R
辨色力Colorse
se耳Ears心Heart
f脊柱Spi
e其他所见Otherab
ormalfi
di
gs
四肢Extremities
神经系统Nervoussystem
胸部X线检查ChestXRayexam
心电图ECG
化验室检查包括血清学诊断r