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КАТЕГОРИИ:
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Physical Examination Record for Foreigner
姓 名
Name
|
| 性别
Sex
| □男 Male
□女 Female
| 出 生 日 期
Birth Day-Month-Year
|
|
照
片
Photo
| 现在通讯地址
Present Mailing Address
|
| 血 型
Blood
type
| 国 籍
Nationality
|
| 出生地址
Birth Place
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| 伤寒和副伤寒 Typhoid and paratyphoid fever
流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis
| | □ No □Yes
□ No □Yes
□ No □Yes
□ No □Yes
| | 菌 痢 Bacillary dysentery
布氏杆菌病 Brucellosis
病毒性肝炎 Viral hepatitis
产褥期链球菌感染
Puerperal streptococcus infection
| | □No □Yes
□No □Yes
□No □Yes
□No □Yes
□No □Yes
| | Typhus fever
Poliomyelitis
Diphtheria
Scarlet fever
Relapsing fever
| | 斑 疹 伤寒
小儿麻痹症
白 喉
猩 红 热
回 归 热
| | 过去是否患有下列疾病(每项后面请回答“否”或“是”)
Have you ever had any of the following diseases?
(Each item must be answered “Yes” or “No”)
| 毒 物 瘾 Toxicomania .....................................................
精神错乱 Mental confusion ..................................................
精 神 病 Psychosis: 躁狂型 Manic Psychosis ..............................
妄想型 Paranoid Psychosis ............................
幻觉型 Hallucinatory Psychosis .........................
| | □ No □Yes
□ No □Yes
□ No □Yes
□ No □Yes
□ 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”)
Do you have any of the following diseases or disorders endangering the public order and security?
(Each item must be answered “Yes” or “No”)
| 身高
Height cm
| 体重
Weight kg
| 血压
Blood pressure mmHg
| 发育情况
Development
| 营养情况
Nourishment
| 颈部
Neck
| 视力 左 L
Vision 右 R
| 矫正视力 左 L
Corrected vision 右 R
| 眼
Eyes
| 辨色力
Colour Sense
| 皮肤
Skin
| 淋巴结
Lymph nodes
| 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
Nervous system
| 其它所见
Other abnormal findings
|
胸部X线
检查
Chest X-ray
Exam.
|
|
心 电 图
E C G
|
|
化验室检查
包括血清学诊断
Laboratory
Exam.
(Serodiagnosis)
|
| Venereal Disease □No □Yes
Opening lung tuberculosis □No □Yes
AIDS □No □Yes
Psychosis □No □Yes
| | Cholera □No □Yes
Yellow fever □No □Yes
Plague □No □Yes
Leprosy □No □Yes
| | 是否发现患有下列检疫传染病和危害公共健康的疾病:
Do you have any of the following diseases or disorders found during the present examination?
(Each item must be answered “Yes” or “No”)
|
意见 检查单位盖章
Suggestion Official Stamp
医师签字 日期
Signature of Physician Date
| | | | | | |
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