2《外国人体格检查记录》表

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1、外国人体格检查记录PHYSICALEXAMINATIONRECORDFORFOREIGNER姓名Name性别□男MaleSex□女Female出生年月BirthDayMonthYear照片photo国籍Nationality出生地BirthPlace血型BloodType现在通讯地址Presentmailingaddress过去是否患有下列疾病：（每项后面请回答“否”或“是”）Haveyoueverhadanyofthefollowingdiseases?(Eachitemmustbeanswered“Yes”or“No”)斑疹伤寒Typhu

2、sfever□No□Yes细菌性痢疾Bacillarydysentery□No□Yes小儿麻痹症Poliomyelitis□No□Yes布氏杆菌病Brucellosis□No□Yes白喉Diphtheria□No□Yes病毒性肝炎Viralhepatitis□No□Yes猩红热Scarletfever□No□Yes产褥期链球菌Puerperalstreptococcus□NO□Yes回归热Relapsingfever□No□Yes感染infection□No□Yes伤寒和副伤寒Typhoidandparatyphoidfever□No□Yes

3、流行性脑脊髓膜炎Epidemiccerebrospinalmeningitis□No□Yes是否患有下列危及公共秩序和安全的病症：（每项后面请回答：“否”或“是”）Doyouhaveanyofthefollowingdiseasesordisordersendangeringthepublicorderandsecure?(Eachitemmustbeanswered“Yes”or“No”)毒物瘾Toxicomania………………………………………………………………………………□No□Yes精神错乱Mentalconfusion…………………

4、…………………………………………………□No□Yes精神病Psychosis：躁狂型Manicpsychosis…………………………………………………□No□Yes妄想型Paranoidpsychosis………………………………………………□No□Yes幻觉型Hallucinatorypsychosis………………………………………□No□Yes身高/Height(厘米/cm)体重/Weight(公斤/kg)血压/pressureBlood(毫米汞柱/mmHg)发育情况Development营养情况Nourishment颈部Neck视力Vis

5、ion左L右R矫正视力Correctedvision左L右R眼Eyes辨色力/Colorsense皮肤/Skin淋巴结/Lymphnodes耳/Ears鼻/Nose扁桃体/Tonsils3心/Heart肺/Lungs腹部/Abdomen脊柱/Spine四肢/Extremities神经系统/Nervoussystem其他所见/Otherabnormalfindings胸部X线检查/ChestX-rayexam心电图/ECG化验室检查(包括艾滋病、梅毒血清学诊断)/LaboratoryExam(HIV,SyphilisSerodiagnosis)

6、未发现患有下列检疫传染病和危害公共健康的疾病：Noneofthefollowingdiseasesordisordersfoundduringthepresentexamination.霍乱Cholera性病VenerealDisease黄热病Yellowfever开放性肺结核Openinglungtuberculosis鼠疫Plague艾滋病AIDS麻风Leprosy精神病Psychosis意见Suggestion检查单位盖章OfficialStam医师签字：日期：Signatureofphysician：Date：3外国人体格检查记录PH

7、YSICALEXAMINATIONRECORDFORFOREIGNER体检说明EXPLANATIONOFTHEPHYSICALEXAMINATION1．在华学习六个月以上的外国留学生，应按照“外国人体格检查记录”进行体格检查。体检表贴照片处，应有医院印章，否则，视体检表无效。Ⅰ．Theforeignstudents,whointendtostudyinChinafor6monthsormore,shouldgothroughaphysicalcheck-upbeforetheycometoChina,accordingtotherequire

8、mentsofPhysicalExaminationRecordforForeigners.Thehospitalsealshouldbeputacrossthep