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             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

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