出入境人员健康检查申请表 HEALTH EXAMINATION REGISTRATION FROM FOR THE PERSONS OF ENTRY-EXIT | ||||||||
姓名Name | 职业 Occupation | |||||||
已婚 Married | □是Yes □否No | 文化程度 Education | ||||||
电话 Tel No. | 前往国家 Destination | |||||||
现单位Prent Working Company | ||||||||
现地址Prent Address | ||||||||
病史问卷 Medical History Questionaire(在医生指导下完成answer the following questions in the prence of the doctor) | ||||||||
过去是否患有下列疾病或危及公共秩序和安全的病症：如有请在下列相应疾病栏回答有，并详细说明。 Have you ever had any of the following dias or disorders endangering the public order and curity? If you have or ever had ,Plea answer Yes in the relative dia and specify. | ||||||||
斑 疹 伤 寒 Typhoid fever | 劳动合同下载 □有 Yes | 菌痢 Bacillary dyntery | □有 Yes | 小儿麻痹症 Poliomyelitis | □有 Yes | |||
布氏杆菌病 Brucellosis | □有 Yes | 白喉 Diphtheria | □有 Yes | 病毒性肝炎 Virus hepatitis | □有 Yes | |||
猩红热 Scarlet fever | □有 Yes | 回归热 Relapsing fever | □有Yes | 精神错乱 Mental confusion在线读书 | □有 Yes | |||
精神病： 躁狂型 Manic Psychosis： 妄想型 Paranoid 幻觉型 Hallucinatory | □有 Yes | 毒物瘾 Toxicomania | □有 Yes | 艾滋病 AIDS | 红配绿赛狗屁 □有 Yes | |||
□有 Yes | 伤寒和副伤寒Typhoid and paratyphoid fever | □有 Yes | 性病 Venereal Dia | □有 Yes | ||||
□有 Yes | 疟疾 Malaria | □有 Yes | 结核 Tuberculosis | □有 Yes | ||||
产褥期链球菌感染（已生育女性填写） Puerperal streptococcus infection（For the bore women） | □有 Yes | 流行性脑脊髓膜炎Epidemic cerebrospinal meningitis | □有 Yes | 其他传染病 Other infections dia | □有 Yes | |||
最近7天内您是否有发热和咳嗽？□有 Have you had a fever or cough within the last 7days? □Yes 是否现患或曾患有其他疾病史？ □有 Have or had you ever had any other dias？ □Yes | ||||||||
如果没有患有上述疾病或症状，请回答：□没有 党的基本知识If never have or had any dias or symptoms which mentioned above , plea answer：□午夜夫妻电影No 如果曾写给孩子的诗/现患有上述疾病或症状，请详细说明：If have or had any dias or symptoms which mentioned above , plea specify: | ||||||||
签证必须检查项目(Required Tests for visa): 身高、体重、血压、体温、内外科、五官科、心电图、B超（肝胆脾、双肾）、X光胸片、血液检测（血型、谷丙转氨酶、乙肝表面抗原、艾滋病抗体、梅毒抗体、丙肝抗体），尿分析、血常规等 。 Height, Weight, Blood Pressure, Temperature, Internal Medicine, ENT, EKG,B-ultrasound,(liver, gallbladder, spleen and kidneys), Chest X-ray, Blood Test(Blood Type, ALT, HBsAg， HIV, TPPA（or TRUST）, Anti-HCV), Urinalysis and Blood Routine，etc。 本人申明以上提供的资料真实，已核对个人资料无误，并已知道体检内容，同意进行体检。 I declare that the information I have provided above is true to the best of my knowledge and I have checked that my personal information is correct and I understand what is to be done during the examination and agree to have the examination which is mentioned above. 签名小满习俗Signature: | ||||||||
推荐检查项目(Recommended Tests): 容积是什么□乙肝四项（乙肝表面抗体、乙肝e抗原、乙肝e抗体、乙肝核心抗体）□ 甲肝抗体二项。□生化12项（肝功能：谷草转氨酶、谷氨酰转肽酶、总蛋白、白蛋白、球蛋白、白/球。血脂：总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇。肾功能：血尿素氮、血肌酐。其它：血尿酸、血糖），□甲胎蛋白(肝癌检查) 癌胚抗原（肠癌检查）□EB病毒（鼻咽癌筛查）。 □B超检查:男性前列腺。 □骨密度检测。 □粪便培养。 □粪便常规。□乙肝表面抗体（定量、定性）。□乙肝病毒基因检测。□PPD试验。 □ Test for Hepatitis B( HBsAb,HBeAg,HBeAb,HBcAb).□ HBsAb（Quantitative、Qualitative）□Test for Hepatitis A(HAV-IgM,HAV-IgG). □Biochemical test: （Test for Liver function: AST, r-PT, T.Prot ，ALB, GLOB, A/G. Test for Blood-Lipid: CHOL,TG,HDL-C,LDL-C. Test for Kidney function: BUN, Creatinine. Other: UA, GLU. ）. □AFP（Test for Hepatic carcinoma）.CEA(Test for Intestinal Carcinoma) □VCA-IgA（Screening test for Nasopharyngeal Carcinoma）.□B-ultrasonic examination for Prostate(Male).□Examination for a bone densitometry. □Feces culture.□Feces Routine. □ HBsAb（Quantitative、Qualitative）. □HBV-DNA.□PPD test. □其他：Other: □ 妇科: □B超检查子宫及附件。 □.电脑乳腺红外线检查。□ 妇女内外生殖器官检查+电脑辅助细胞学筛查(宫颈癌检查)。 Gynecological examination: □B-ultrasonic examination for Womb and Appendage.□Computer Diaphanography Imaging .□Edeoscopy and Secretion routine ,Cervical exfoliative cytoliative examination by computer assistant (Examination for Cervical carcinoma.) | ||||||||
我已知道推荐的体检内容，同意进行上述检查。 I understand what is recommended and agree to get the examination which is mentioned above. 签名:signature: | ||||||||
□外文翻译 份 □X光报告、携带X光片 □HIV报告 □签发其它检查检验报告 □验证 □验血 □B超检查（肝、胆、脾、双肾） | ||||||||
备注： 审核医生签名： 日期: 年 月 日. date： | ||||||||
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