外国人体检表

发稿时间:2019-04-02 来源:江苏财会职业学院 作者: 摄影: 浏览次数:143

 

PHYSICAL EXAMINATION RECORD FOR FOREIGNER AND HONGKONG  MACAO  TAIWAN  COMPATRIOT

 

 

Name

 

性别

Sex

□男 Male

□女 Female

出生日期\ 

Birth   Day-Month-Year

    

(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

 

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”

伤寒    Typhus fever    No Yes            Bacillary dysentery        No Yes

小儿麻痹症    Poliomyelitis    No Yes     布氏杆菌病  Brucellosis              No Yes

          Diphtheria      No Yes     病毒性肝炎  Viral hepatitis           No Yes

        Scarlet fever    No Yes     产褥期链球  Puerperal streptococcus infection

        Relapsing fever  No Yes                                 No Yes

伤寒和副伤寒  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”)

 

   Toxicomania…………………………………………………………………………□No Yes

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

   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    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

 

Spine

 

 

Extremities

 

神经系统

Nervous system

 

其它所见

Other abnormal   findings

 

 X 线

(附检查报告单)

Chest X-ray

Exam

(Attached

chest X-ray

report

 

 

心电图

ECG

 

(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)

 

丙型肝炎抗体/Anti-Hcv

丙氨酸基转移酶/GPT(<29U/L)

梅毒确认试验/TPPA

艾滋病病毒抗体/Anti-HIV

 

 

 

 

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

 

     Cholera                          Venereal Disease

黄热病   Yellow fever                 肺结核    lung tuberculosis

     Plague                      艾滋病   AIDS

     Leprosy                       精神病   Psychosis

                                                     检查单位盖章

Suggestion   无异常发现。                                             Official Stamp

 

 

 

 

 

 

 

医师签字                                  日期                   

Signature of physician                            Date




















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