姓 名 Name | 性别 男Male Sex 女Female | 出生日期 ____年___月___日 Date of Birth | 照片 Photo Put ospital al across the photo | |||||||||||||
现在通迅地址 Prent mailing adderss | 血型 Blood Type | |||||||||||||||
国籍 Natio- nality | 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 diasEach ietm must be answered “Yes”or “No” | ||||||||||||||||
斑疹伤寒 Typhus fever 细菌性痢疾Bacillary dyntery | ||||||||||||||||
小儿麻痹症 Poliomyelitis 布氏杆菌病 Brucellosis | ||||||||||||||||
白 喉 Diphtheria 病毒性肝炎 Viral hepatitis | ||||||||||||||||
猩 红 热 Scarlet fever 产褥期链球菌 Puerperal streptococcus | ||||||||||||||||
回 归 热 Relapsing fever 感 染 Infection | ||||||||||||||||
伤寒和副伤寒 Typhoid and paratyphoid fever | ||||||||||||||||
流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis | ||||||||||||||||
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 dias or disorders endangering the public order and cure Each item most be answered “Yes” or “No” 毒物瘾 Toxicomani接字开头的成语a···················································· 精神错乱 Mental confusion ··············································· 兔子怎么吃精神病Psychosis：躁狂型 Manic psychosis ······························· 妄想型 Paranoid psychosis ······························ 幻觉型 Hallucinatory psychosis ·························· | ||||||||||||||||
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 朝着阳光奔跑Corrected vision | 左L 右R | 眼Eyes | ||||||||||||
辨色力/Color n | 皮肤/Skin | 愉快的歌曲淋巴结/Lymph nodes | ||||||||||||||
耳/Ears | 鼻/No | 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 ExamHIV, Syphilis Serodiagnosis | 附上对以下项目的化验室报告：Plea attach the results and data sheets for the following items:AIDS.,Syphilis,ALT.,AST.,T-BIL.,and HbsAG. | |||||||||||||||
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 dias or disorders found during the prent examination 霍 乱 Yholera 性 病 Venereal Dia 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 检查单位盖章 Suggestion Official Stamp 致富故事医师签字 日 期 媚光四射Signature of physician Date | ||||||||||||||||
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