PHYSICAL EXMINATION RECORD FOR FOREIGNER - …

1 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?

2 (each item must be answered No or Yes ) Toxicomania Mental confusion /No /Ye s /No /Ye s Psychosis Manic psychosis Paranoid psychosis Hallucinatory psychosis /No /Ye s /No /Ye s /No /Ye s Height cm We i g h t kg Blood presure ~ mmHg Development Nourishment Neck Vision L R Corrected vision L R Eyes Colour sense Skin Lymph nodes Ears Nose Tonsils Heart Lungs Abdomen Spine Extremities Nervous system Other abnormal findings X Chest X-ray exam attached chest X-ray report ECG Laboratory exam HIV, Syphilis serodiagnosis attached test report of AIDS.

3 Syphilis etc None of the following diseases or disorders found during the present examination: /No /Ye s Cholera Yellow fever Plague Leprosy Venereal diseases Opening lung tuberculosis AIDS Psychosis Suggestion Signature of physician Official stamp Date 1 2 1 2 B 3 1 2 3 4 1 2 5 6