外国人体格检查记录

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

Offical Stamp)

现在通讯地址

Present mailing address

血型

Blood

type

国  籍

Nationality

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     布氏杜菌病  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

是否患有下列危及公共秩序和安全的疾病：（每项后面请回答“否”或“是”）

Do you have any of the following diseases or disorders endangering the pubic order and security?

(Each item must be answered “Yes” or “No”)

毒 物 瘾   Toxicomania………………………………………………………………………………□No □Yes

神经错乱   Mental confusion…………………………………………………………………………□No □Yes

神 经 病   Psychosis: 躁狂型 Manic psychosis……………………………………………………□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                 千帕

Blood pressure         KPa

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 sense

皮肤

Skin

淋巴结

Lymph nodes

耳

Ears

鼻

Nose

扁桃体

Tonsils

心

Heart

肺

Lungs

腹部

Abdomen

脊  柱

Spine

四  肢

Extremities

神经系统

Nervous system

其它所见

Other abnormal findings

胸 部 X 线

检 查 结 果

（附检查报告单）

Chest X-ray

Exam

(Attached

chest X-ray

report

心电图

ECG

化 验 室 检 查

（包括HIV抗体、梅毒等血清学检查,并附原始检查报告单）

Laboratory exam

(Attached test report of AIDS, Syphilis etc)

HIV-1/2抗体（初筛）/Anti-HIV 1/2 (Screen)                    

梅毒初筛试验（定性）/Syphilis screen(Quality)                      

乙型肝炎表面抗原/HBsAg                   

丙型肝炎抗体/Anti-HCV                

ALT                  

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                 肺结核    lung tuberculosis

鼠  疫   Plague                      艾滋病   AIDS

麻  风   Leprosy                     精神病   Psychosis

意    见                                                 检查单位盖章

Suggestion                                                Official Stamp

医师签字                                  日期

Signature of physician                            Date