外国人体格检查记录[008].docVIP

外国人体格检查记录PHYSICAL EXAMINATION RECORD FOR FOREIGNER姓 名Name性别Sex□ 男□ 女出生日期Birth Day-Month-Year照片Photo现在通讯地址Present mailing address血型Blood type国籍Nationality出生地址Birth Place过去是否患有下列疾病：（每项后面请回答“否”或“是”）Have you ever had any of the following diseases?(Each item must be answered “Yes” or “No”)　斑疹伤寒 Typhus fever □ No □ Yes 菌　　　痢 Bacillary dysentery □ No □ Yes　小儿麻痹症 Poliomyelitis □ No □ Yes 布氏杆菌病 Brucellosis □ No □ Yes　白　　　喉 Diphtheria □ No □ Yes 病毒性性肝炎 Viral hepatitis □ No □ Yes　猩 红 热 Scarlet fever □ No □ Yes 产褥期链球菌 Puerperal streptococcus infection 感染 □ No □ Yes　伤寒和付伤寒 Typhoid and paratyphoid fever