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3ForeignerPhysicalExaminationFormSample

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11 views

3ForeignerPhysicalExaminationFormSample

Uploaded by

alone.raja40
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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外国人体格检查记录

PHYSICAL EXAMINATION RECORD FOR FOREIGNER


体 检 说 明
EXPLANATION OF THE PHYSICAL EXAMINATION
1．在华工作或学习六个月以上的外国人，应按照“外国人体格检查记录”进行体格检查。
体检表贴照片处，应有医院印章，否则，视体检表无效。
Ⅰ．Foreigners,, who intend to work or study in China for over 6 months, should go through
a physical check-up before they come to China, according to the requirements of Physical
Examination Record for Foreigners. The hospital seal should be put across the photo on the
Examination Record, or the Record is invalid.

2．体检表应填写清楚，体检报告应附有 X 光透视胸片及霍乱、黄热、鼠疫、麻风、性
病、开放性肺结核、艾滋病、肝功能、澳抗和精神病的化验室检查报告。
Ⅱ．All the items of this form should be filled in carefully and clearly. The
report should be attached with the negative film for Chest X-ray exams, and the
examination certificates for laborstory exams (Serodiagnosis), which include
exams on Cholera, Yellow fever, Plague, Leprosy, Venereal Disease, Opening lung
tuberculosis, AIDS, Psychosis, Liver function and HB&AG.

3.体检应在来华一个月前在公立医院进行，凡在私立医院体检者，应取得公证部门的公
证。
Ⅲ.The physical examination should be taken in the public hospitals one month
before their departure, If the physical check-up is done at a private hospital,
the student should get the certificate notarized.

4.体检表是办理入境签证及在华居留手续所需文件之一。
Ⅳ.The Physical Examination Form is one of the documents that is needed in the
process of going through the visa formalities. The students should bring the
original copy along with them when they come to China.
外 国 人 体 格 检 查 表
FOREIGNER PHYSICAL EXAMINATION FORM
姓名 性别 □ 男 Male 出生日期 照片
Name Sex □ 女 Female Birthday (加盖检查单位印章)

现在通讯地址
Present mailing address Photo
(Stamped Official
国籍或地区 出生地 血型
Stamp)
Nationality Birth Blood type
(or Area) 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”)

班疹 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 Puerperal streptococcus infection
回 归 热 Relapsing fever □No □Yes 菌 感 染 □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 you have any of the following diseases 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 paychosis…………………………………□No □Yes
妄想型 Paranoid psychosis………………………………□No □Yes
幻觉型 Hallucinatory……………………………………□No □Yes

身高 厘米 体重 公斤 血压 毫米汞柱
Height CM Weight Kg Blood pressure mmHg

发育情况 营养情况 颈部
Development Nourishment Neck

视力 左 L 矫正视力 左L 眼
Vision 右R Corrected vision 右 R Eyes

辨色力 皮肤 淋巴结
Colour sense Skin Lymph nodes

耳 鼻 扁桃体
Ears Nose Tonsils

心 肺 腹部
Heart Lungs Abdomen
四肢 神经系统
脊柱 Extremities Nervous system
Spine

其他所见
Other abnormal findings

心电图
胸部 X 线 ECC
检查结果
(附检查报告单)
Chest X-ray exam
(attached chest X-ray
report)

化验室检查
(包括艾滋病、
梅毒等血清学检查)
Laboratory exam
(attached test report of
AIDS, Syphilis etc)

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 of disorders found during the present examination.
霍乱 Cholera 性病 Venereal Disease
黄热病 Yellow fever 肺结核 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

医师签字 日期
Signature of physician Date

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