Transcription of PHYSICAL EXMINATION RECORD FOR FOREIGNER - …
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PHYSICAL EXMINATION RECORD FOR FOREIGNER - …
PHYSICAL EXMINATION RECORD FOR FOREIGNER Name Sex Male Female Birth D/M/Y / / D / M / Y Address Blood type Nationality Birth place Photo Have you ever had any of the following diseases? (each item must be answered No or Yes ) Typhus fever Poliomyelitis Diphtheria Scarlet fever Relapsing fever /No /Ye s /No /Ye s /No /Ye s /No /Ye s /No /Ye s Bacillary dysentery Brucellosis Viral hepatitis Puerperal streptococcus infection /No /Ye s /No /Ye s /No /Ye s /No /Ye s Typhoid and paratyphoid fever Epidemic cerebrospinal meningitis /No /Ye s /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 exmination record for foreigner. 姓 名
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