现在通讯地址

Present mailing address

国籍或地区

Nationality (or Area)

出生地

Birth place

血型

Blood type

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 小儿麻痹症   Poliomyelitis    □No □Yes 白        喉     Diphtheria        □No  □Yes 猩   红   热    Scarlet fever    □No  □Yes 回 归 热 Relapsing fever □No □Yes

菌              痢              Bacillary dysentery              □No □Yes

布氏杆菌病              Brucellosis              □No  □Yes

病毒性肝炎              Viral hepatitis              □No □Yes

产褥期链球              Puerperal streptococcus infection

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

Height              CM

体重              公斤

Weight              Kg

血压              毫米汞柱

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

辨色力

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

其他所见

Other abnormal findings

胸部X线检查结果

(附检查报告单)

Chest X-ray exam (attached chest X-ray report)

心电图ECC

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