境外人員體格檢查記錄

1、境外人員體格檢查記錄YesPHY SICAL EXAMINATION RECORD FOR FOREIGNER斑疹傷寒 小兒麻痹癥 白 猩 回Typhus feverPoliomyelitis DiphtheriaScarlet feverNo No No No No No Yes No Yes No YesYes 產(chǎn)褥期鏈球菌 Puerperal streptococcus infectionYes菌Yes布氏桿菌病Yes病毒性肝炎痢 Bacillary dysentery BrucellosisViral hepatitisYes 感染 No YesRelaps ing fever 傷寒和

2、付傷寒Typhoid and paratyphoid fever No Yes流行性腦脊髓膜炎 Epidemic cerebrospinal meningitis No Yes姓名Name性別Sex男 Male 女 Female出生日期Date of Birth Day/Mo nth/Year照片Photo現(xiàn)在通訊Prese ntu地址address血型Blood type國籍Nati on ality出生地址Birth Place過去疋否患有以下疾病內(nèi).(每項丿口面請答復(fù) 疋 或 否)Have you ever had any of the follow ing diseases? (Eac

3、h item must be an swereda K |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(fù)“是或“否)Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered“Yes or “No)毒物癮 Toxicomania 精神錯舌 L Men talc on fusi on 精神病 Psychosis:躁狂型 Manic psychosis 妄想型 Paranoid psycho

4、sis 幻覺型 Hallucinatory psychosis 厘米cmNoYesNoYesNoYesNoYesNoYes身高Height 發(fā)育情況Developme nt 視力左 LVisio n 右 R辨色力Colour sense耳Ears心Heart編號：42 (19X27 cm)體重Weight營養(yǎng)情況Nourishme nt矯正視力 左 LCorrected Visio n 右 R 皮膚Ski n鼻Nose肺Lungs公斤kg血 壓Blood pressure 頸部Neck眼Eyes 淋巴結(jié)Lymph no des扁桃體Ton sils腹部Abdome n毫米汞柱mmHg脊柱四肢S

5、pi neExtremities神經(jīng)系統(tǒng)Nervous system其他所見Other abno rmal findings肺部X線 檢杳Chest X-ray Exam.心電圖ECG化驗室檢杳包括血清學(xué)診斷Laboratory Exam.(Serodiag no sis)未發(fā)現(xiàn)患有以下檢疫傳染病和危害公共健康的疾?。篘one of the follow ing diseases or disorders found duri ng the prese nt exam in atio n霍亂Cholera性病Venereal Disease黃熱病 Yellow fever開放性肺結(jié)核 Opening lung tuberculosis鼠疫Plagus艾滋病AIDS麻風(fēng)Lepro