外国人体格检查记录
外国人xx 记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
验证证明
CERTIFICATE OF VERIFICATION
姓名性别
Name ________ Sex ___________________ 国籍出生日期
Nationality ____ Date of Birth _____________
发证日期护照号码
Issued Date _____ Passport Number ___________________
现在通信地址
Present Address ________________________
兹证明上列人员所持外国人体格检查记录,经过验证,符合要求。
This is to certify that the bearer ' s Physical Examination Record for Foreig accord with the requirement. 医师签字验证单位盖章Signature of Physician Official stamp 日期
Date __________________
外国人xx 记录
PHYSICIAL EXAMINATION RECORD FOR FOREIGN名性别男口Male出生日
期
Birth Day -Mo nth-Year
Name Sex 女□ Female
照片现在通讯地址血型Present Mailing Address Blood
Photo Type
国籍出生地址
Nationality Birth Place 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”)
斑疹伤寒Typhus fever □ No □ Y菌痢Bacillary dysentery □ Yes^J□儿麻
痹症Poliomyelitis □ No CflY S s杆菌病Brucellosis □ Yes □白喉Diphtheria □ No □ Yes病毒性肝炎Vital hepatis □ Ye猩红热yoScarlet fever □ No □ Yes
产褥期链球菌感染Puerperal Streptoccus Infection □ No □ Yes
回归热Relapsing fever □ No □ Yes
伤寒和副伤寒Typhoid and paratyphoid fever □ Yes流行性脑脊髓膜炎
Epidemic cerebrospi nal menin gitis 是否e患有MN列危及公共秩序和安全的
病症：
(每项后面请回答“否”或“是”) D o you have any of the following diseases or disorders endangering the public order and security?
(Each item must be answered “Yes” or “ No”)
精神错乱Mental confusion ......................... □Yes □ No
精神病Psychosis 躁狂型Manic psychosis ........ □ Yes □ No
妄想型Paranoid psychosis ...... □Yes □ No
幻觉型Hallucinatory psychosis …口Yes □ No 身高
Height cm
发育情况
Development 视力左L
Vision 右R
辨色力
Color sense 耳Ears 心Heart 体重血压
Weight kg Blood pressure mmHg 营养情况Nourishment
矫正视力左L _____
Corrected vision 右R
皮肤
Skin 鼻Nose 肺Long 颈部
Neck 眼Eye
淋巴结
Lymph nodes
扁桃体
Tonsils
腹部
Abdomen
脊柱
Spine
其他所见
Other abnormal findings 胸部X 线检查Chest X- Ray exam 心电图ECG
四肢
Extremities 神经系统
Nervous system 化验室检查包括血清学诊断
Laboratory
Exam
( Serodiagnosis ) 未发现患有下列检疫传染病和危害公共健康的疾病
None of the following diseases or disorders found during the present examination.霍乱Cholera 性病Venereal Disease 黄热病Yellow fever 开放性肺结
核Opening lung tuberculosis 鼠疫Plague 爱滋病AIDS 麻风Leprosy 精神病Psychosis 意见检查单位xx
Suggestion Official stamp
医师签字日期
Signature of physician Date