1、外國人體格檢查記錄PHY SICAL EXAMINATION RECORD FOR FOREIGNER過去是否患有以下疾病：(每項后面請答復：“否或“是)Have you ever had any of the follow ing diseases?(Each item must be answered “ Yes斑疹傷寒Typhus fever No Yes菌痢Bacillary dyse ntery No Yes小兒麻痹癥Poliomyelitis No Yes布氏桿菌病Brucellosis No Yes白喉Diphtheria No Yes病毒性肝炎Viral hepatitis N

2、o Yes猩紅熱Scarlet fever No Yes回歸熱Relaps ing fever No Yes No No No Yes Yes YesPuerperal streptococcus infection Typhoid and paratyphoid fever Epidemic cerebrosp inal menin gitis產褥期鏈球菌感染 傷寒和付傷寒流行性腦脊髓膜炎or “ No )是否患有以下危及公共秩序和平安的病癥：(每項后面請答復“否或“是)Do you have any of the follow ing diseases or disorders endan

3、 geri ng the public order and security? (Each item must be an swered“ Yes or“ No)Toxicoma nia毒物癮精神錯亂精神病 Psychosis：Me ntal Con fusi on躁狂型妄想型幻覺型身高Height發育情況厘米cmDevelopme nt視力左LVision 右 R辨色力Colour sense耳EarsHeartMan ic psychosisPara noid psychosisHallucinatory psychosis千克Weight營養情況Nourishme nt左LCorrect

4、ed vision 右 R矯正視力Ski n鼻NoseLungsKgBlood pressure頸部NeckEyes 淋巴結Lymph no des 扁桃體Ton silsAbdome n No Yes No Yes No Yes No Yes No Yes千帕Kpa姓名Name性別Sex男 Male女 Female岀生日期Birth Day-Month-Year昭八、片Photo(StampedOfficial Stamp )現在通訊地址Prese nt maili ng address血型Bloodtype國籍Natio nality出生地址Birth Place脊柱Sp ine四肢Ext

5、remities神經系統Nervous system其它所見Other abno rmal findings胸部X線檢查Chest X -ray exam.心電圖ECG化驗室檢杳包括艾滋病、 梅毒血清學診斷Laboratory exam.(HIV, Syphilis Serodiag no sis)未發現患有以下檢疫傳染病和危害公共健康的疾病：None of the follow ing diseases or disorders found duri ng the prese nt exam in ati on.霍舌 LCholera性病 Ven ereal Disease黃熱病 Yellow fever開 放性肺 結核Opening lung tuberculosis鼠疫Plague艾滋病AIDS麻風Lepro