姓 名

Name

性别

Sex

□男Male

□女Female

出生日期

Birthday-Month-Year

照 片

photo

现在通讯地址

Present mailing

address

血型

Blood

type

国 籍

Nationality

出生地址

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”)

斑诊伤寒Typhus fever □No□Yes菌 痢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 Infection

□No□Yes

回归热Relapsing fever□No□Yes 感染Infection □No□Yes

伤寒和付伤寒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 yo have any of the following diseases or disorders endangering the public order 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

Height cm

体重

Weight Kg

血压

Blood pressure 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

Corrected vision右R

眼

Eyes

辩色力

Colour 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

其它所见

Other abnormal findings

胸部X线

检查

Chest X-ray

Exam

心电图

ECG

化验室检查（包括爱滋病、梅毒等血清诊断）

Laboratory

Exam.

(AIDS. Syphilis etc. Serodiagnosis)

未发现患有下列建议传染病和危害公共健康的疾病:

None of the following diseases or disorders found during the president 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 爱滋病AIDS

麻风 Leporsy 精神病Psychosis

意见 卫生检疫机关或检查单位盖章

Suggestion Official Stamp

医师签字 日期

Signature Date