外國(guó)人體檢表

1、外國(guó)人體格檢查記錄PHYSICALEXAMINATIONRECORDFORFOREIGNER祎姓名羃 Name薀性另嗎廠Male莈 Sex 女Female薅出生日期年月日肅 DateofBirthy.m.d.肇現(xiàn)在通迅地址蒈Prese ntmaili ngadderss膃血型膃BloodType_ * _ _i1i L / *葿國(guó)籍羅Natio-膆n ality芃出生地衿 Birth蚇 Place1 莄(Putospitalsealacrosstheph oto)羄過去是否患有下列疾?。海宽?xiàng)后面請(qǐng)回答“否”或“是”）莃 Haveyoueverhadanyofthefollowingdisea

2、ses?(Eachietmmustbeanswered 螁斑疹傷寒Typhusfever 細(xì)菌性痢疾 Bacillarydysentery蕿小兒麻痹癥PoliomyelitisBrucellosis芄白喉Diphtheria病毒性肝炎Viralhepatitis亠 口卄螂猩紅熱 Scarletfever產(chǎn)褥期鏈球菌 Puerperalstreptococcus袂回歸熱Relaps in gfever感染而ection羂傷寒和副傷寒 Typhoida ndparatyphoidfever羈照片螆 PhotoYes or No 蚃流行性腦脊髓膜炎Epidemiccerebrosp in alme

3、nin gitis罿 Doyouhaveanyofthefollowingdiseasesordisordersendangeringthepublicorderandsecure?肇（Eachitemmostbeanswered“Yes” or “ No"） 莀毒物癮Toxicomani a芁精神錯(cuò)舌 L Men talc on fusion 膄精神病 Psychosis :躁狂型 Manicpsychosis 蚆妄想型 Paranoidpsychosis ' 口荿幻覺型 Hallucinatorypsychosis蒈身高/Height（厘米/cm）肆體重/Weight（公

4、斤/kg）血壓 /PressureBlood（毫米汞柱 /mmHg）發(fā)育情況Developme nt營(yíng)養(yǎng)情況Nourishme nt頸部Neck視力左L矯正視力左L眼 EyesVisio n右RCorrected右Rvisio n辨色力 /Colorsense皮膚/Skin淋巴結(jié) /Lymph no des耳/Ears鼻 /Nose扁桃體/Tonsils心/Heart肺 /Lungs腹部 /Abdomen脊柱/Spi ne四肢 /Extremities1 1 1O j 弋 d神經(jīng)系統(tǒng) /Nervoussystem其他所見Otherab no rmalfi ndingsI f1' L|胸

5、部X線檢查/Chest X-rayexam心電圖/ECG化驗(yàn)室檢查(包括艾滋 病、梅毒血清學(xué)診斷)/LaboratoryExam(HIV,SyphilisSerodiag nosis)附上對(duì)以下項(xiàng)目的化驗(yàn)室報(bào)告：Pleaseattachtheresultsa nddatasheetsforthefollowi ngitems:AIDS.,Syphilis,ALT.,AST.,T-BIL.,a ndHbsAG.未發(fā)現(xiàn)患有下列檢疫傳染病和危害公共健康的疾病Non eofthefollow in gdiseasesordisordersfo un dduri ngtheprese ntexam in ati on 霍亂 Yholera 性病 VenerealDisease 黃熱病 Yellowfever 開放性肺結(jié)核 Openinglungtuberculosis 鼠疫Plague艾滋病AIDS 麻風(fēng) Lepro