境外人員體格檢查記錄

1、境外人員體格檢查記錄PHYSICAL EXAMINATION RECORD FOR FOREIGNER OR OVERSEAS CHINESE姓 名Name性別Sex男Male女Female出 生 日 期Birthday-Month-Year照 片 photo 現在通訊地址Present mailing address血 型Blood type國 籍Nationality出生地址Birth Place過去是否患有下列疾病：（每項后面請回答“否”或“是”）Have you ever had any of the following diseases?(Each item must be answ

2、ered “Yes” or “No”)斑診傷寒Typhus fever No Yes 菌 痢Bacillary dysenteryNoYes小兒麻痹癥 PoliomyelitisNo Yes 布氏桿菌病 Brucellosis NoYes白 喉 Diphtheria No Yes 病毒性肝炎 Viral Hepatitis No Yes猩紅熱 Scarlet fever No Yes 產褥期鏈球菌Puerperal Streptococcus Infection NoYes回歸熱 Relapsing fever No Yes 感染 Infection NoYes傷寒和付傷寒 Typhoid a

3、nd paratyphoid 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：（每項后面請回答“否”或“是”）Do yo have any of the following diseases or disorders endangering the public order security? (Each item must be answered “Yes” or “No”)毒物癮 Toxicomania No Yes精神錯亂Mental confusionNo Yes精神病Psy

4、chosis：躁狂型Manic psychosis. No Yes 妄想型Paranoid psychosis . No Yes 幻覺型Hallucinatory psychosis. No Yes身高Height cm 體重Weight Kg血壓Blood pressure mmHg發(fā)育情況Development 營養(yǎng)情況Nourishment 頸部Neck 視 力 左LVision 右R矯正視力 左LCorrected vision 右R眼Eyes辯色力Colour sense 皮膚Skin淋巴結Lymph Nodes耳Ears 鼻Nose扁桃體Tonsils心Heart 肺Lungs 腹

5、部Abdomen脊柱Spine 四肢Extremities神經系統(tǒng)Nervous system其它所見Other abnormal findings胸部X線檢查Chest X-rayExam心 電 圖ECG化驗室檢查（包括愛滋病、梅毒等血清診斷）LaboratoryExam.(AIDS. Syphilis etc. Serodiagnosis)未發(fā)現患有下列建議傳染病和危害公共健康的疾病:None of the following diseases or disorders found during the president examination霍亂 Cholera 性病Venereal Disease黃熱病Yellow fever 開放性肺結核Opening Lung Tuberculosis鼠疫 Plague 愛滋病AIDS麻風