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1、外国人体格检查表外国人体格检查表 姓名 Name FOREIGNER PHYSICAL EXAMINATION FORM 性别 男 Male 出生日期 Sex 女 Female Birth Day Month - Year 出生地址 Birth Place 照 片 (加盖检查 单位印章) 现在通信地址 Present mailing address 国籍或地区 Nationality (or Area) 血型 Blood type Photo (stamped Official stamp) 过去是否患有下列疾病： Have you ever had any of the following
2、deseases? (Each item must be answered “Yes” or “No”) 斑 疹 伤 寒 Typhus fever NoYes 菌 痢 Bacillary dysentery NoYes 小儿麻痹症 Poliomyelitis NoYes 布氏杆菌病 Brucellosis NoYes 白 喉 Diphtheria NoYes 病毒性肝炎 Viral hepatitis NoYes 猩 红 热 Scarlet fever NoYes 产褥期链球 Puerperal streptococcus infection 回 归 热 Relapsing fever NoY
3、es 菌 感 染 NoYes 伤寒和付伤寒 Typhoid and paratyphoid fever NoYes 流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis NoYes 是否患有下列危机公共秩序和安全的病症： 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 NoYes 精神错乱 Metal
4、 confusion NoYes 精神病 Psychosis：躁狂型 Manic Paychosis NoYes 妄想型 Paranoid psychosis NoYes 幻想型 Hallucinatory psychosis NoYes 身高 厘米 体重 公斤 血压 毫米汞柱 Height CM Weight kg Blood pressure mmHg 发育情况 营养情况 颈部 Development Nourishment Neck 视力 左L_ 矫正视力 左L_ 眼 Vision 右R Corrected vision 右R Eyes 辨色力 皮肤 淋巴结 Colour senses
5、Skin Lymph nodes 耳 鼻 扁桃体 Ears Nose Tonsils 心 肺 腹部 Heart Lungs Abdomen 脊 柱 四 肢 神经系统 Spine Extremities Nervous system 其它所见 Other abnormal findings 胸部X线 检查结果 心电图 Chest X-ray ECG Exam (attached chest X-ray report) 化验室检查 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：
6、 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 意 见 检查单位盖章 Suggestion Official Stamp 医师签字 日期 Signature of physician Date The foreigners are suppose
7、d to take the physical examination before leaving in a national or regional public hospital and get report of all the items listed in the form with the signature of the doctor and the stamp of the hospital. If the check is done in a private hospital or clinic, the report should be notarized by a pub
8、lic notary. The form submitted should be the original copy with the photo of the examinee and supporting documentations such as laboratory report sheets, X-ray films and necessary testing reports. The Administration of Quality supervision, Inspection and Quarantine will double check the submitted fo
9、rm and attached documentations upon their arrival and decide whether its acceptable or they should take additional or another physical examination. If additional check or re-check is required, the student should follow the requirement and pay for their own. The double check fee is RMB 60.00 yuan which should be covered by the students themselves.
