外國人體格檢查表范本

1、外國人體格檢查表外國人體格檢查表PHYSICALEXAMINATIONRECDFFEIGNERS姓名姓名Name性別性別Sex□男Male□女Female出生日期出生日期Dateofbirth現(xiàn)在通訊地址現(xiàn)在通訊地址Presentmailingaddress血型血型Bloodtype國籍國籍Nationality出生地址出生地址BirthPlace照片照片Photo過去是否患有下列疾?。海宽?xiàng)后面請回答“否”或“是”過去是否患有下列疾病

2、：（每項(xiàng)后面請回答“否”或“是”）Haveyoueverhadanyofthefollowingdisease（Eachitemmustbeanswered“Yes”“No”）斑疹傷寒斑疹傷寒Typhusfever□NoNo□YesYes菌痢菌痢BacillaryBacillarydysenterydysentery□NoNo□YesYes小兒麻痹癥小兒麻痹癥PoliomyelitisPoliomyelitis□NoNo□YesYes布

3、氏桿菌布氏桿菌BrucellosisBrucellosis□NoNo□YesYes白喉白喉DiphtheriaDiphtheria□NoNo□YesYes病毒性肝炎病毒性肝炎ViralViralhepatitishepatitis□NoNo□YesYes猩紅熱猩紅熱ScarletScarletfeverfever□NoNo□YesYes產(chǎn)褥期鏈球菌產(chǎn)褥期鏈球菌PuerperalPuerperalstreptococcusstreptoc

4、occusinfectioninfection回歸熱回歸熱RelapsingRelapsingfeverfever□NoNo□YesYes□NoNo□YesYes傷寒和副傷寒傷寒和副傷寒Typhoidparatyphoidfever□NoNo□YesYes流行性腦脊髓膜炎流行性腦脊髓膜炎EpidemicEpidemiccerebrospinalcerebrospinalmeningitismeningitis□NoNo□YesYes是否

5、患有下列危及公共秩序和安全的病癥：（每項(xiàng)后面請回答“否”或“是”是否患有下列危及公共秩序和安全的病癥：（每項(xiàng)后面請回答“否”或“是”）Doyouhaveanyofthefollowingdiseasedisdersendangeringthepublicdersecurity（Eachitemmustbeanswered“Yes”“No”）毒物癮毒物癮Toxicomania□NoNo□YesYes精神錯(cuò)亂精神錯(cuò)亂MentalMental

6、confusionconfusion□NoNo□YesYes精神病精神病Psychosis：狂躁型：狂躁型Manicpsychosis□NoNo□YesYes妄想型妄想型ParanoidParanoidpsychosispsychosis□NoNo□YesYes幻覺型幻覺型HallucinatyHallucinatypsychosispsychosis□NoNo□YesYes身高身高Heightcm體重體重Weight血壓血壓Blood

7、pressure發(fā)育情況發(fā)育情況Development營養(yǎng)狀況營養(yǎng)狀況Nourishment頸部頸部Nest視力視力左LVision右R矯正視力矯正視力左LCrectedvision右R眼E辨色力辨色力Colsense皮膚皮膚Skin淋巴結(jié)淋巴結(jié)Lymphnods耳Ears鼻Nose扁桃體扁桃體Tonsils心Heart肺Lungs腹部腹部Abdomen脊柱脊柱Spine四肢四肢Extremities神經(jīng)系統(tǒng)神經(jīng)系統(tǒng)Nervoussys

8、tem其他所見其他所見Otherabnmalfindings胸部胸部X線檢查線檢查ChestX—rayexam心電圖心電圖ECG化驗(yàn)室檢查化驗(yàn)室檢查（包括血清學(xué)診斷）（包括血清學(xué)診斷）LabatyExam（Serodiagnosis）未發(fā)現(xiàn)患有下列檢疫傳染病和危害公共健康的疾病未發(fā)現(xiàn)患有下列檢疫傳染病和危害公共健康的疾病Noneofthefollowingdiseasesdisdersfoundduringthepresentexami