医院标志-roc-taiwanorg.DOCVIP

醫院標誌 Hospital’s Logo 健康檢查證明應檢查項目表（乙表） （醫院名稱、地址、電話、傳真機） ITEMS REQUIRED FOR HEALTH CERTIFICATE （Form B） （Hospital’s Name, Address, Tel, FAX） 檢查日期 ____/____/____ (年) (月) (日) ____/____/____ (Ｍ) (Ｄ) (Ｙ) Date of Examination 基 本 資 料 ( BASIC DATA) 實　驗　室　檢　查 (LABORATORY EXAMINATIONS) A. 胸部X光檢查肺結核（Chest Ｘ-Ray for Tuberculosis）： X光發現(Findings)： 判定()：□合格(Passed)□不合格(Failed) (經臺灣健檢醫院判定為疑似肺結核或無法確認診斷者，得至指定機構複驗；但所在縣市無指定機構者，得至鄰近醫院之胸腔科門診複檢。) (Those who are determined to be TB suspects or have a pending diagnosis by the designated hospital in Taiwan must visit the referred institution for further evaluation.) □孕婦或兒童12歲以下免驗 (Not required for pregnant women or children under 12 years of age) B.腸內寄生蟲（含痢疾阿米巴等原蟲）糞便檢查（採用離心濃縮法檢查）（Stool examination for parasites includes Entameba histolytica etc.）(centrifugal concentration method)： □陽性，種名( Positive, Species ) ______________________ □陰性（Negative） □其他可不予治療之腸內寄生蟲(Other parasites that do not require treatment) ____________________ □兒童6歲以下或來自特定地區者免驗 (Not required for children under 6 years of age or applicants from designated areas as described in Note 6) C.梅毒血清檢查（Serological Test for Syphilis）： 檢驗(Tests)：.□RPR或□VDRL ______________ ｂ.□TPHA/TPPA _______________ ｃ.□其它（Other）___________ 判定()：□合格(Passed)□不合格(Failedproof of positive measles and rubella antibody titers or measles and rubella vaccination certificates）： a.抗體檢查（Antibody test ) 麻疹抗體measles antibody titers □陽性 Positive □陰性 Negative □未確定（Equivocal） 德國麻疹抗體rubella antibody titers □陽性 Positive □陰性 Negative □未確定（Equivocal） b.預防接種證明 Vaccination Certificates (含接種日期、接種院所及疫苗批號；接種日期與出國日期應至少相隔兩週。The Certificate should include the date of vaccination, the name of administering hospital or clinic and the batch no. of vaccine; the date of vaccination should be at least two weeks prior to going abroad) □麻疹預防接種證明Vaccination Certificates of Measles □德國麻疹預防接種證明Vaccination