外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
体 检 说 明
EXPLANATION OF THE PHYSICAL EXAMINATION
Ⅰ．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 toChina.
外国人体格检查记录
PHYSICAL EXAMINATION RECORD FOR FOREIGNER
姓名
Name
| | 性别 □男Male
Sex □女Female
| 出 生 月 年
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 answered“Yes”or“No”)
|
斑疹伤寒Typhus fever□No□Yes 细菌性痢疾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 □NO□Yes
|
回归热Relapsing fever □No□Yes 感染infection □No□Yes
|
伤寒和副伤寒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 secure?
(Each item most 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 (厘米/ cm)
| 体重/
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
| 视力 左L
Vision 右R
| 矫正视力 左L
Corrected vision 右R
|
巩膜
Sclera
| 夜盲
Night Blindness
| 辨色力
Colour sense
|
皮肤
Skin
| 淋巴结
Lymph nodes
| 耳
Ears
|
听力 左L
Hearing 右R
| 鼻
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
|
心
Heart Rhythm
| 肺
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.
霍 乱Cholera 性 病Venereal Disease
黄热病Yellow fever 开放性肺结核Opening lung tuberculosis
鼠 疫Plague 艾 滋 病AIDS
麻 风Leprosy 精 神 病Psychosis
|
意 见 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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