附件2-Health Exam Form 体检表
更新日期:2018-10-30

外国人体格检查记录

PHYSICAL EXAMINATION RECORD FOR FOREIGNER

     

EXPLANATION OF THE PHYSICAL EXAMINATION

 

The foreign teachers, who intend to work in China for 6 months of more, 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.

 

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. On their arrival at University, the Record (a original copy) and laboratory exam certificates should be sent to Yunnan Quarantine Bureau for check. Those whose exam is not qualified should get the physical re-check up done in Yunnan. The expenses should be covered by themselves.

 

 

III. The Physical Examination Form is one of the documents that is needed in the process of going through the visa formalities. The teachers should bring the original copy along with them when they come to China.

 

 

 

 

 

 

 

 

 

 

 

 


外国人体格检查记录

PHYSICAL EXAMINATION RECORD FOR FOREIGNER

Name

性别  □男Male

Sex   □女Female

                  

Birth Day    Month       Year

照片

photo

现在通讯地址

Present mailing address

血型

Blood Type

国籍

Nationality

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 diseases? (Each item must be answeredYesorNo)

Typhus fever NoYes    细菌性痢疾 Bacillary dysentery         NoYes

小儿麻痹症Poliomyelitis  NoYes    布氏杆菌病Brucellosis                 NoYes

     Diphtheria     NoYes    病毒性肝炎Viral hepatitis              NoYes

Scarlet fever     NoYes    产褥期链球菌 Puerperal streptococcus    NOYes

Relapsing fever  NoYes    infection                       NoYes

伤寒和副伤寒 Typhoid and paratyphoid fever                  NoYes

流行性脑脊髓膜炎  Epidemic cerebrospinal meningitis          NoYes

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 secure?

(Each item most be answered YesorNo)

毒物瘾 Toxicomania………………………………………………………………………………□NoYes

精神错乱Mental confusion ………………………………………………………………………□NoYes

精神病Psychosis:躁狂型  Manic psychosis……………………………………………………□NoYes

                妄想型  Paranoid psychosis…………………………………………………□NoYes

                幻觉型  Hallucinatory psychosis……………………………………………□NoYes

Height            (厘米/ cm)

/

Weight            (公斤/ kg)

血压

Blood Pressure          (千帕/Kpa)

脉率

Pulse rate                                      

发育情况

Development                   

营养情况

Nourishment        

颈部Neck

   L

Vision   R

     L

Corrected vision   R

 

巩膜

Sclera

夜盲

Night Blindness

辨色力

Colour sense

皮肤

Skin                                        

淋巴结

Lymph nodes                      

Ears

听力    L

Hearing  R                                                         

Nose                            

嗅觉

Smell

咽喉

Thorat

扁桃体

Tonsils

口腔粘膜

Mucosa of mouth

牙齿

Teeth

甲状腺

Thyroid

胸廓

Thoracic Shape

Heart Rhythm                                                           

Lungs                             

腹部

Abdomen

脊柱

Spine

四肢

Extremities

 

B型超声B-Ultrasound

 

 

 

胸部X线检查

Chest X-ray exam

心电图

ECG

 

 

 

化验室检查(包括艾滋病、梅毒诊断)/Laboratory Exam [including Anti-HIV, Syphilis screen, HBaAg, Anti-HCV, ALT(GPT)]

 

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 or disorders found during the present examination.

  Cholera                               Venereal Disease

黄热病 Yellow fever                   开放性肺结核Opening lung tuberculosis

  Plague                              AIDS

  Leprosy                             Psychosis

                                                                医院盖章

Suggestion                                                       Stamp of Hospital

                                 

 

 

 

 

 

 

 

 

 

医师签字                                                          日期

Signature of physician: ______________            Date:  D_____ M _____Y______

 

 

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