外国人体格检查记录
PHYSICALEXAMINATIONRECORDFORFOREIGNER
姓名Name
性别Sex
男Male
出生日期
____年___月___日
女FemaleDateofBirthy___m___d___
照片
现在通迅地址Prese
tmaili
gadderss国籍Natio
出生地Birth
血型BloodType
PhotoPutospitalsealacrossthe
photo
ality
Place
过去是否患有下列疾病:每项后面请回答“否”或“是”
Haveyoueverhada
yofthefollowi
gdiseasesEachietmmustbea
swered“Yes”or“No”
斑疹伤寒Typhusfever
NoYes细菌性痢疾Bacillarydyse
tery
NoYes
小儿麻痹症Poliomyelitis
NoYes布氏杆菌病Brucellosis
NoYes
白喉
Diphtheria
NoYes病毒性肝炎Viralhepatitis
NoYes
猩红热Scarletfever
NoYes产褥期链球菌PuerperalstreptococcusNoYes
回归热Relapsi
gfeverNoYes感染I
fectio
NoYes
伤寒和副伤寒Typhoida
dparatyphoidfever
NoYes
流行性脑脊髓膜炎Epidemiccerebrospi
alme
i
gitis
NoYes
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
dsecure
Eachitemmostbea
swered“Yes”or“No”毒物瘾Toxicoma
iaNoYes
精神错乱Me
talco
fusio
NoYes
精神病Psychosis:躁狂型Ma
icpsychosis
NoYes
妄想型Para
oidpsychosisNoYes
幻觉型Halluci
atorypsychosisNoYes
身高Height厘米cm
体重Weight公斤kg
血压PressureBlood毫米汞柱mmHg
发育情况Developme
t
营养情况Nourishme
t
颈部Neck
视力左LVisio
右R辨色力Colorse
se
矫正视力左L
Corrected
visio
右R
皮肤Ski
眼Eyes淋巴结Lymph
odes
耳Ears
鼻Nose
扁桃体To
sils
心Heart
肺Lu
gs
腹部Abdome
f脊柱Spi
e
四肢Extremities
神经系统Nervoussystem
其他所见Otherab
ormalfi
di
gs
胸部X线检查ChestXrayexam
心电图ECG
化验室检查包括艾滋病、梅毒血清学诊断LaboratoryExamHIVSyphilisSerodiag
osis
附上对以下项目的化验室报告:Pleaseattachtheresultsa
ddatasheetsforthefollowi
gitemsAIDSSyphilisALTASTTBILa
dHbsAG
未发现患有下列检疫传染病和危害公共健康的疾病
霍乱黄热病鼠疫麻风
No
eofthefollowi
gdiseasesordisordersfou
dduri
gtheprese
texami
atio
Yholera
性
病Ve
erealDisease
Yellowfever
开放性肺结核Ope
i
glu
gtuberculosis
Plague
艾滋病AIDS
Leprosy
精神病Psychosis
意见Suggestio
检查r