1、外國人體格檢查表FOREIGNER PHYSICAL EXAMINATION FORM姓名性別男 Male出生日期NameSex女 FemaleBirthday現在通訊地址Prese nt maili ng address出生地血型照片加蓋檢查單位印章國籍或地區Natio nality(or Area)BirthplaceBlood typePhoto(Stamped OfficialStamp)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 an swere

2、dToxicoma niaNo YesMen tal con fusi onNo YesPsychosis：躁狂型Manic paychosisNo Yes妄想型Para noid psychosisNo Yes幻覺型Halluc in atoryNo Yes身高厘米體重公斤血壓毫米汞柱HeightCMWeightKgBlood pressuremmHg發育情況Developme nt營養情況Nourishme nt頸部Neck視力左LVision右 R矯正視力左LCorrected vision 右 R_Eyes辨色力Colour sense皮膚Skin淋巴結Lymph no des班疹 傷

3、寒 Typhus fever No Yes小兒菌痢Bacillary dyse ntery No Yes麻痹癥Poliomyelitis No Yes 白布氏桿菌病Brucellosis No Yes喉 Diphtheria No Yes 猩紅病毒性肝炎Viral hepatitis No Yes熱Scarlet fever No Yes 回歸產褥期鏈球Puerperal streptococcus in fecti on熱Relapsi ng fever No Yes菌感染 No Yes傷寒和付傷寒Typhoid and paratyphoid fever No Yes流行性腦脊髓膜炎Epi

4、demic cerebrosp inal menin gitis No Yes)是否患有以下危及公共秩序和平安的病癥:Yes ora k | No每項后面請答復“否或“是Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be an swered“ Yes or“ No)毒物癮精神錯亂精神病扁桃體EarsNoseTon sils腹部HeartLungsAbdome n脊柱Spi ne四肢Extremities神經系統Ne

5、rvous system其他所見Other abno rmal findings胸部X線檢查 結果(附檢查報 告單)Chest X-ray exam (attached chest X-ray report)心電圖ECC化驗室檢杳(包括 艾滋病、梅毒等血 清學檢查)Laboratory exam (attached test report ofAIDS, Syphilis etc)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 of disorders found duri ng the prese nt exam in atio n. 霍亂Cholera性病Ven ereal Disease黃熱病Yellow fever肺結核Lu ng tuberculosis鼠疫Plague艾滋病AIDS麻風Lep