姓 名

Name

性别  □男Male

Sex   □女Female

出    生      月         年

Birth Day    Month       Year

照片

photo

现在通讯地址

Present mailing address

血型

Blood Type

国籍

Nationality

出生地

Birth Place

过去是否患有下列疾病：（每项后面请回答“否”或“是”）

Have you ever had any of the following diseases? (Each item must be answered“Yes”or“No”)

斑 疹 伤 寒 Typhus fever □No□Yes    细菌性痢疾 Bacillary dysentery         □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Viral hepatitis              □No□Yes

猩 红 热Scarlet fever     □No□Yes    产褥期链球菌 Puerperal streptococcus    □NO□Yes

回 归 热 Relapsing fever  □No□Yes    感 染infection                       □No□Yes

伤寒和副伤寒 Typhoid and paratyphoid fever                  □No□Yes

流行性脑脊髓膜炎  Epidemic cerebrospinal meningitis          □No□Yes

是否患有下列危及公共秩序和安全的病症：（每项后面请回答：“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”)

毒物瘾 Toxicomania………………………………………………………………………………□No□Yes

精神错乱Mental confusion ………………………………………………………………………□No□Yes

精神病Psychosis：躁狂型  Manic psychosis……………………………………………………□No□Yes

                妄想型  Paranoid psychosis…………………………………………………□No□Yes

                幻觉型  Hallucinatory psychosis……………………………………………□No□Yes

身 高/Height (厘米/ cm)

体 重/ Weight (公斤/ kg)

血压/pressure Blood(毫米汞柱/mmHg)

发育情况Development                                           

营养情况Nourishment                         

颈部Neck

视 力

Vision

左L

右R

矫 正 视 力

Corrected vision

左 L

右R

眼Eyes

辨 色 力/Color sense                                                  

皮肤/Skin                            

淋巴结/Lymph nodes

耳/Ears                                                            

鼻/Nose                              

扁桃体/Tonsils

心/Heart                                                           

肺 /Lungs                             

腹部/Abdomen

脊柱/Spine                                                  

四肢/Extremities

神经系统/Nervous system

其他所见/Other abnormal findings

胸部X线检查/Chest X-ray exam

心电图/ECG

化验室检查(包括艾滋病、梅毒血清学诊断)/Laboratory Exam (HIV, Syphilis Serodiagnosis)

未发现患有下列检疫传染病和危害公共健康的疾病：

None of the following diseases or disorders found during the present examination.

霍  乱 Cholera                       性        病 Venereal Disease

黄热病 Yellow fever                   开放性肺结核Opening lung tuberculosis

鼠  疫 Plague                        艾   滋   病 AIDS

麻  风 Leprosy                       精   神   病 Psychosis

意  见

Suggestion

                           检查单位盖章

                           Official Stamp

  医师签字                                            日期

Signature of physician                                        Date