外国人体格检查记录PHYSICALEXAMINATIONRECORDFORFOREIGNER
姓名Name现在通讯地址Prese
tmaili
gaddress国籍Natio
ality出生地址BirthPlace性别Sex□男Male□女Female出生日期BirthDayMo
thYear血型loodtype照片Photo
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“No”斑疹伤寒Typhusfever□No□Yes菌痢Bacillarydyse
tery□No□Yes□No□Yes小儿麻痹症Poliomyelitis□No□Yes布氏杆菌病Brucellosis白喉Diphtheria□No□Yes病毒性肝炎Viralhepatitis□No□Yes猩红热Scarletfever□No□Yes产褥期链球菌感染Puerperalstreptococcusi
fectio
回归热Relapsi
gfever□No□Yes□No□Yes伤寒和付伤寒Typhoida
dparatyphoidfever□No□Yes流行性脑脊髓膜炎Epidemiccerebrospi
alme
i
gitis□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”）Doyouhavea
yofthefollowi
gdiseasesordisorderse
da
geri
gthepublicordera
dsecurityEachitemmustbea
swered“Yes”or“No”毒物瘾Toxicoma
ia…………………………………………………………………□No□Yes精神错乱Me
talco
fusio
……………………………………………………………□No□Yes精神病Psychosis躁狂型Ma
icPsychosis………………………………………□No□Yes妄想型Para
oidpsychosis……………………………………□No□Yes幻觉型Halluci
atorypsychosis………………………………□No□Yes身高Height发育情况Developme
t视力左LVisio
右R辨色力Colorse
se耳Ears心Heart体重Weight营养情况Nourishme
t矫正视力左LCorrectedVisio
右R皮肤Ski
鼻Nose肺Lu
gs血压Bloodpressure颈部Neck眼Eyes淋巴结Lymph
odes扁桃体Lymph
odes腹部Abdome

cm
kg
mmHg
f脊柱Spi
e其它所见Otherab
ormalfi
di
gs
四肢Extremities
神经系统Nervoussystem
胸部X线检查ChestXrayexam
心电图ECG
HIVAbIIIRPRTPHA
化验室检查包括血清学诊断LaboratoryexamSerodiag
osis
HAVIgMHbsAgHcVAbSGPT
未发现患有下列检疫传染病和危害公共健康的疾病：No
eofthefollowi
gdiseasesordisordersfou
dduri
gtheprese
texami
atio
霍乱Cholera黄热病Yellowfever鼠疫Plague麻风Leprosy意见Suggestio
性病开放性肺结核艾滋病精神病Ve
erealDiseaseOpe
i
glu
gtuberculosisAIDSPsychosis检查单位盖章OfficialStamp
医师签字Sig
atureofphysicia

日期Date
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