首页 > 资料下载 > 来华留学

physical exam form体检表.doc

外 国 人 体 格 检 查

FOREIGNER PHYSICAL EXAMINATION FORM

姓名

Name

性别

Sex

Male

Female

出生日期

Birthday

照片 (加盖检查单位印章)

Photo (Stamped Official

Stamp)

现在通讯地址

Present mailing address

国籍或地区 Nationality (or Area)

出生地 Birth place

血型

Blood type

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 “Yesor “No”)

班疹 伤寒 Typhus fever No Yes 小儿麻痹症 Poliomyelitis No Yes 白 喉 Diphtheria No Yes 猩 红 热 Scarlet fever No Yes 回 归 热 Relapsing fever No Yes

Bacillary dysentery No Yes

布氏杆菌病 Brucellosis No Yes

病毒性肝炎 Viral hepatitis No Yes

产褥期链球 Puerperal streptococcus infection

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 “Yesor “No”)

毒物瘾 ToxicomaniaNo Yes

精神错乱 Mental confusion……………………………………………□No Yes 精神病Psychosis躁狂型 Manic paychosisNo Yes 妄想型              Paranoid psychosis………………………………□No Yes

幻觉型 HallucinatoryNo 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 L

Vision R

矫正视力 L

Corrected vision R

Eyes

辨色力

Colour sense

皮肤

Skin

淋巴结

Lymph nodes

Ears

Nose

扁桃体

Tonsils

Heart

Lungs

腹部

Abdomen













脊柱

Spine

四肢

Extremities

神经系统

Nervous system

其他所见

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 ECC

化验室检查 (包括艾滋病、 梅毒等血清学检查)

Laboratory exam (attached test report of AIDS, Syphilis etc)

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 of 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

检查单位盖章

Suggestion Official Stamp

医师签字 日期

Signature of physician Date