Transcription of PHYSICAL EXAMINATION RECORD FOR FOREIGNER
1 PHYSICAL EXAMINATION RECORD FOR FOREIGNER . Male . Name Sex Female Birth day . present mailing address Photo Blood type Nationality Birth place . Have you ever had any of rhe following diseases? Typhus fever No Yes Bacillarydysentery No Yes Poliomyelitis No Yes Brucellosis No Yes Diphtheria No Yes Viral hepatitis No Yes Scarlet fever No Yes puerperal streptococcus infection Relapsing fever No Yes No Yes Typhoid & paratyphoid fever No Yes Epidemic cerebrospinal meningitis No Yes . Do you have any of the following diseases or disorders endangering the public order and security? Toxicomamia No Yes Mental confusion No Yes Psychosis Manic psychosis No Yes Paranoid psychosis No Yes Hallucinatory psychosis No Yes . Height cm Weight Kg Blood Pressure mmHg . Development Nourishment Neck L L . Vision R Corrected vision R Eyes . Colour sense Skin Lymph nodes.
2 Ears Nose Tonsils . Heart Lungs Abdomen * Please turn over the form . Spine Extremities Nervous system . other abnormal findings X . chest X-ray exam ECG.. Laboratory exam (Serodiagnosis).. None of the following diseases or disorders found during the present EXAMINATION Cholera venereal disease Yellowfever Openning lung Tuberculosis Plague AIDS. leprosy Psychosis . Suggestionj . Official Stamp . Signature of physician Date End of the form
