Transcription of PHYSICAL EXAMINATION RECORD FOR FOREIGNER
1 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?
2 (Each item must be answered "Yes" or "No") Toxicomania .. No Ye s Mental confusion .. No Ye s Psychosis Manic Psychosis .. No Ye s Paranoid psychosis .. No Ye s Hallucinatory psychosis .. No Ye s Weight kg Blood pressure mmHg Height cm Development Nourishment Neck L Corrected vision R Eyes L Vision R Colour sense Skin Lymph nodes Nose Tonsils Ears Heart Lungs Abdomen 42 19 27cm Spine Extremities Nervous system Other abnormal findings X Chest X-ray Exam.
3 ( ) (attached chest X-ray report) ECG Laboratory Exam. (HIV Syphilis Serodiagnosis ) Attached test Report of AIDS Syphilis etc None of the following diseases or disorders found during the present EXAMINATION . Cholera Venereal Disease Yellow fever Opening lung tuberculosis Plague AIDS Leprosy Psychosis Suggestion Official Stamp Signature of physician Date
