| 姓名
Name
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性别Sex
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□男Male
□女Female
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出生日期
Date of birth
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照 片
Photo
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| 现在通讯地址
Present Mailing Address
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血型
Blood
Type
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国籍
Nationality
出生地点
Birth Place
过去是否患过下列疾病（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菌痢Bacillary dysentery□No □Yes
小儿麻痹症Poliomyclitis □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产褥期链球菌感染 Puerperal streptococcus infection
回归热Relapsing fever□No□Yes□No□Yes
伤寒和副伤寒Typhoid and paratyphoid□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:狂躁型 Manic Psychosis………………………………………………………□No □Yes
妄想型Paranoid Psychosis……………………………………………………□No □Yes
幻觉型 Hallucinatory Psychosis……………………………………………□No □Yes
身高
Height
体重
Weight
血压
Blood pressuremmHg
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
辩色力
Color 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
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四肢
Extremities
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神经系统
Nervous system
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| 其它所见
Other abnormal findings
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| 胸部X线检查
Chest X-ray Exam
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心电图
ECG
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| 化验室检查
包括血清学诊断
Laboratory
Exam
Serodiagnosis
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| 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 examinations
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
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意见检查单位盖章
SuggestionOfficial Stamp
医师签字日期
Signature of physicianDate
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