境外人員體格檢查記錄(共3頁(yè))

1、精選優(yōu)質(zhì)文檔-傾情為你奉上境外人員體格檢查記錄PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓名Name性別Sex 男Male 女 Female出生日期Date of Birth Day/Month/Year 照 片 Photo現(xiàn)在通訊地址Present address血型Blood type 國(guó) 籍Nationality出生地址Birth Place過(guò)去是否患有下列疾病：(每項(xiàng)后面請(qǐng)回答“是”或“否”)Have you ever had any of the following diseases? (Each item must be answered “

2、Yes” or “No”)斑疹傷寒 Typhus fever No Yes 菌 痢 Bacillary dysentery No Yes小兒麻痹癥 Poliomyelitis No Yes 布氏桿菌病 Brucellosis No Yes 白 喉 Diphtheria No Yes 病毒性肝炎 Viral hepatitis No Yes猩 紅 熱 Scarlet fever No Yes 產(chǎn)褥期鏈球菌Puerperal streptococcus infection 回 歸 熱 Relapsing fever No Yes 感染 No Yes傷寒和付傷寒 Typhoid and paraty

3、phoid fever No Yes流行性腦脊髓膜炎 Epidemic cerebrospinal meningitis No Yes是否患有下列危及公共秩序和安全的病癥：(每項(xiàng)后面請(qǐng)回答“是”或“否”) Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered “Yes”or “No”) 毒 物 癮 Toxicomania No Yes 精神錯(cuò)亂 Mentalconfusion No Yes 精 神

4、病 Psychosis: 躁狂型 Manic psychosis No Yes 妄想型 Paranoid psychosis No Yes 幻覺(jué)型 Hallucinatory psychosis No Yes身高 厘米Height cm 體重 公斤Weight kg血 壓 毫米汞柱Blood pressure mmHg發(fā) 育 情 況Development營(yíng) 養(yǎng) 情 況Nourishment頸部Neck視 力 左 L Vision 右 R矯 正 視 力 左 L Corrected Vision右 R眼Eyes辨 色 力Colour sense皮膚Skin淋 巴 結(jié)Lymph nodes耳Ears

5、鼻Nose扁桃體Tonsils心Heart肺Lungs腹部Abdomen編號(hào)： 42 （19X27 cm）脊柱 Spine四肢Extremities神經(jīng)系統(tǒng)Nervous system其他所見(jiàn)Other abnormal findings肺部X線 檢查Chest X-rayExam. 心電圖 ECG 化驗(yàn)室檢查包括血清學(xué)診斷 LaboratoryExam.(Serodiagnosis)未發(fā)現(xiàn)患有下列檢疫傳染病和危害公共健康的疾?。篘one of the following diseases or disorders found during the present examination 霍 亂 Cholera 性 病 Venereal Disease 黃 熱 病 Yellow fever 開(kāi)放性肺結(jié)核 Opening lung tuberculosis 鼠 疫 Plagus 愛(ài) 滋 病 AIDS 麻 風(fēng) Leprosy 精 神 病 Psy