外  国  人  体  格  检  查  表 

FOREIGNER PHYSICAL EXAMINATION FORM 

姓名 

Name 

 

性别 

Sex 

□ 

男 Male 

□ 

女 Female 

出生日期 

Birthday 

 

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

 

照片 

(加盖检查单位印章)

 

 

Photo 

(Stamped Official 

Stamp) 

 

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 

 

脊柱 

Spine 

 

 

四肢 

Extremities

 

神经系统 

Nervous system 

 

 

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