1、外國人體格檢查記錄PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓 名性別男 Male出生月年NameSex女 FemaleBirth DayMonthYear現在通訊地址血型照片Present mailing addressBlood Typephoto國籍出生地NationalityBirth Place過去是否患有下列疾病： （每項后面請回答“否”或“是”）Have you ever had any of the following diseases? (Each item must be answered “ Yes” or“ No ” )斑 疹 傷

2、 寒 Typhus fever No Yes細菌性痢疾Bacillary dysentery No Yes小兒麻痹癥 Poliomyelitis No Yes布氏桿菌病 BrucellosisNo Yes白喉 Diphtheria No Yes病毒性肝炎 Viral hepatitis No Yes猩 紅 熱 Scarlet fever No Yes產褥期鏈球菌Puerperal streptococcus NO Yes回 歸 熱 Relapsing fever No Yes感 染 infection No Yes傷寒和副傷寒 Typhoid and paratyphoid fever No

3、Yes流行性腦脊髓膜炎Epidemic cerebrospinal meningitis No Yes是否患有下列危及公共秩序和安全的病癥：（每項后面請回答：“否”或“是”）Do you have any of the following diseases or disorders endangering the public order and secure?(Each item most be answered “ Yes” or“ No ” )毒物癮 Toxicomania ,No Yes精神錯亂 Mental confusion,No Yes精神病 Psychosis：躁狂型Manic

4、 psychosis ,No Yes妄想型Paranoid psychosis,No Yes幻覺型Hallucinatory psychosis ,No Yes身 高 /Height ( 厘米 / cm)體 重 / Weight ( 公斤 / kg)血壓 /pressure Blood( 毫米汞柱 /mmHg)發育情況Development營養情況Nourishment頸部 Neck視 力左 L矯正視力左 L眼 EyesVision右 RCorrected vision右 R辨 色 力 /Color sense皮膚 /Skin淋巴結 /Lymph nodes耳/Ears鼻 /Nose扁桃體 /

5、Tonsils心/Heart肺 /Lungs腹部 /Abdomen編號： 42 （19× 27cm）脊柱 /Spine四肢 /Extremities神經系統 /Nervous system其他所見 /Other abnormal findings胸部 X 線檢查 /Chest X-ray exam心電圖 /ECG化驗室檢查 (包括艾滋病、梅毒血清學診斷)/Laboratory Exam (HIV, Syphilis Serodiagnosis)未發現患有下列檢疫傳染病和危害公共健康的疾病：None of the following diseases or disorders foun

6、d during the present examination.霍亂 Cholera性病 Venereal Disease黃熱病 Yellow fever開放性肺結核 Opening lung tuberculosis鼠疫 Plague艾滋病 AIDS麻風 Leprosy精神病 Psychosis意見Suggestion檢查單位蓋章Official Stamp醫師簽字日期Signature of physicianDate編號： 42（19× 27cm）體檢說明EXPLANATION OF THE PHYSICAL EXAMINATION1在華學習六個月以上的外國留學生，應按照 “

7、外國人體格檢查記錄 ”進行體格檢查。體檢表貼照片處，應有醫院印章，否則，視體檢表無效。The foreign students, who intend to study in China for 6 months of more, should go through a physical check-up before they come to China, according to the requirements of Physical Examination Record for Foreigners. The hospital seal should be put across the

8、 photo on the Examination Record, or the Record is invalid.2體檢表應填寫清楚，體檢報告應附有X 光透視胸片及霍亂、黃熱、鼠疫、麻風、性病、開放性肺結核、艾滋病、肝功能、澳抗和精神病的化驗室檢查報告。外國留學生到天津大學報到時，我們將體檢表及化驗室檢查報告送至天津市衛生檢疫局查驗。凡體檢查驗不合格者，需在天津市衛生檢疫局重新檢體，費用自理。All the items of this form should be filled in carefully and clearly. The report should be attached

9、with the negative film for Chest X-ray exams, and the examination certificates for laborstory exams (Serodiagnosis), which include exams on Cholera, Yellow fever, Plague, Leprosy, Venereal Disease, Opening lung tuberculosis, AIDS, Psychosis, Liver function and HB&AG. On their arrival at Universi

10、ty, the Record (a original copy) and laboratory exam certificates should be sent to Tianjin Quarantine Bureau for check.Those whose exam is not qualified should get the physical re-check up done in Tianjin.The expenses should be covered by themselves.3.體檢應在來華一個月前在公立醫院進行，凡在私立醫院體檢者，應取得公證部門的公證。到天津大學報到時

11、， 體檢時間不得超過六個月，否則應在天津重新檢體，費用自理。The physical examination should be taken in the public hospitals one month before their departure, If the physical check-up is done at a private hospital, the student should get the certificate notarized. If the physical check-up is over 6 months old onthe day of their registration, they should have re-check up in Tianjin. The expenses should be covered by themselves.4.體檢表是辦理入境簽證及在華居留手續所需文件之一，留學生到天津大學報到時，應提交正本。The Physical Examination