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

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