现在通讯地址

Presentmailingaddress

血型

Blood

Type

国籍

Nationality

出生地址

Birth Place

过去是患有下列疾病：（每项后面请回答“是”或“否”）

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菌痢Bacillary dysentery□No□Yes

小儿麻痹Poliomyelitis□No□Yes布氏杆菌病Brucellosis□No□Yes

白喉Diphtheria□No□Yes病素性肝炎Viralhepatitis□No□Yes

猩红热Scarlet fever□No□Yes产褥期链球菌Puerperalstreptococcus infection

回归热Relapsing fever□No□Yes感染□No□Yes

伤寒和负伤寒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秩序的病症：（每项后面请回答“是”或“否”）

Do you have any of the following disease or disorders endangering the public order and security? (Each item must 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

身高厘米

Heightcm

体重公斤

Weightkg

血压毫米汞柱

Bloodpressure mmHg

发育情况

Development

营养情况

Nourishment

颈部

Neck

视力左L

Vision右R

矫正视力左L

Correctedvision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

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 disorder were found during the present examination

霍 乱Cholera性 病Venereal Disease

黄 热 病Yellow fever开放性结核Opening lung tuberculosis

鼠 疫Plague艾 滋 病AIDS

麻 风Leprosy精 神 病Psychosis

意见检查单位盖章

SuggestionOfficialStamp

医师签字日期

SignatureofphysicianDate