PHYSICAL EXAMINATION RECORD FOR FOREIGNER

PHYSICAL EXAMINATION RECORD FOR FOREIGNER Name Sex Male Female Birth Day-Month-Year Present mailing address Nationality Birth Place Blood type Photo Have you ever had any of the following diseases? (Each item must be answered "Yes" or "No") Typhus fever No Yes Bacillary dysentery No Ye s Poliomyelitis No Yes Brucellosis No Ye s Diphtheria No Yes Viral hepatitis No Ye s Scarlet fever No Yes Puerperal streptococcus infection Relapsing fever No Yes No Ye s Typhoid and paratyphoid fever No Ye s Epidemic cerebrospinal meningitis No Ye s Do you have any of the following diseases or disorders endangering the public order and security?

外 国 人 体 格 检 查 记 录 PHYSICAL EXAMINATION RECORD FOR FOREIGNER 姓 名 Name 性别 Sex 男 Male 女 Female 出 生 日 期

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