Foreigner Physical Examination Form

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Foreigner Physical Examination Form

2015-04-20

姓名 Name			性别 Sex	□男 Male □女 Female			出生日期 Birth Day – Month - Year			照片 (加盖检查单位印章) Photo (stamped Official stamp)
现在通信地址 Present mailing address								血型 Blood type
国籍或地区Nationality (or Area)			出生地址 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□Yes 菌痢 Bacillary dysentery □No□Yes 小儿麻痹症 Poliomyelitis □No□Yes 布氏杆菌病 Brucellosis □No□Yes 白喉 Diphtheria □No□Yes 病毒性肝炎 Viral hepatitis □No□Yes 猩红热 Scarlet fever □No□Yes 产褥期链球 Puerperal streptococcus infection 回归热 Relapsing fever □No□Yes 菌感染 □No□Yes 伤寒和付伤寒 Typhoid and paratyphoid fever □No□Yes 流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis □No□Yes
是否患有下列危机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" of "No") 毒物瘾 Toxicomania …………………………………………………………………□No□Yes 精神错乱 Metal confusion …………………………………………………………□No□Yes 精神病 Psychosis：躁狂型 Manic Paychosis …………………………………□No□Yes 妄想型 Paranoid psychosis …………………………………□No□Yes 幻想型 Hallucinatory psychosis ………………………………□No□Yes
身高厘米 Height CM					体重公斤 Weight kg				血压毫米汞柱 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 senses					皮肤 Skin				淋巴结 Lymph nodes
耳 Ears					鼻 Nose				扁桃体 Tonsils
心 Heart					肺 Lungs				腹部 Abdomen

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