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Foreigner Physical Examination Form

2015-04-20

 

姓名
Name
 
性別
Sex
□男 Male
□女 Female
出生日期
Birth Day – Month - Year
 
  
(加蓋檢查
單位印章)
 
Photo
(stamped
Official stamp)
現在通信地址
Present mailing address
 
血型
Blood type
國籍或地區Nationality (or Area)
 
出生地址
Birth Place
 
過去是否患有下列疾病:(每項后面請回答“否”或“是”)
Have you ever had any of the following diseases?
(Each item must be answered "Yes" or "No")
斑疹傷寒 Typhus fever     No□Yes          痢 Bacillary dysentery □No□Yes
小兒麻痹癥 Poliomyelitis     No□Yes    布氏桿菌病 Brucellosis         No□Yes
      喉 Diphtheria       No□Yes    病毒性肝炎 Viral hepatitis       □No□Yes
猩 紅 熱 Scarlet fever      No□Yes    產褥期鏈球 Puerperal streptococcus infection
回 歸 熱 Relapsing 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 Epidemic cerebrospinal meningitis       No□Yes   
 
 
是否患有下列危機公共秩序和安全的病癥:(每項后面請回答“否”或“是”)
Do you have any of the following diseases or disorders endangering the public order and security?
(Each item must be answered "Yes" of "No")
 毒物癮 Toxicomania …………………………………………………………………□No□Yes
 精神錯亂 Metal confusion  …………………………………………………………□No□Yes
 精神病 Psychosis:躁狂型 Manic Paychosis     …………………………………□No□Yes
                   妄想型 Paranoid psychosis   …………………………………□No□Yes
                   幻想型 Hallucinatory psychosis  ………………………………□No□Yes
 身高              厘米
 Height             CM
體重             公斤
Weight            kg
血壓             毫米汞柱
Blood pressure       mmHg
 發育情況
 Development
營養情況
Nourishment
頸部
Neck
視力        左L________
 Vision       右R
矯正視力        左L_______
Corrected vision   右R
Eyes
辨色力
 Colour senses
皮膚
Skin
淋巴結
Lymph nodes
 Ears
Nose
扁桃體
Tonsils
 Heart
Lungs
腹部
Abdomen
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