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fl'tr ,fsffi&aiE,tPHYSICAL EXAMINATION RECORD FOR FOREIGNER

w.zName

i4tuSex

! E Male

! Jr Femalef iABHJ

Birth Day-Month-Year Hfl

h

Photo

II./irEifl]UJtPresent mailing address

in ,tI

BIood

typeI=I EE

Nationality

HA'U!lBirth Place

rl*'E6i$fi- l- tltLffi (h,tfrllEi#l,lf "6" q, " E")Have you ever had any ofthe following diseases?

(Each item must be answered

BID$iX Typhus fever lNo nYes ffiffi Bacillary dysentery DNo lYes

4'llhi,Fft Poliomyelitis CNo [Yes /f K,l+H,6* Brucellosis ENo lYes

Effi Diphtheria lNo lYes ,fi6t'*ffi4 Viral hepatitis DNo [Yes

LEZIIA Scarlet fever lNo lYes ,"'FsHllitlF6 Puerperal streptococcus infection

lrlE#l Relapsing fever [No lYes lil+ CNo [Yes(h€f[l'l[h* Typhoid and'paratlphoid fever lNo lYes

,ft{ii*ffiH-ffiH4Epidemiccerebrospinalmeningitis DNo lYes

E6,fr fi r ttft,e,Lr\t*.tr'tuf.4-lfiffift ' ( tt rFliEi€l,l$ " 6 " q. " E" )Do you have any ofthe following diseases or disorders endangering the public order and security?

(Each item must be answered "Yes" or "No")#4fi1E Toxicomania ENo lYes

ffii$tfrilt Mental contusion . . ..*Hi$ifi Psychosis, ffif,i4

EIn4 Paranoid psychosis ..

LJfr,4. Huttu"inuto.y p.y"llo.i,

Manic Psychosis ..

.. lNo [Yes

. . . lNo lYes

.. nNo flYes

.. trNo trYcs

Ef ' t

Height

EHIEOLDevelopment

ftrXcm

l6fi ^flWeight kg

dnd €X:triiBlood pressure mmHg

'e Jr1trtn

Nourishment

iF*tlNeck

+n. h ELVision A R

H+trhColour sense

Lorrected vtsron t] K

IREyes

EntSkin

WElf;Lymph nodes

Ears,L'

Heart

Nose

,li'iD[44Tonsil s

flfiLungs

lFfir IAbdomen

f f iF j , 42 ( l9x27cn)i

iIi r .

!

rti

I

/

tr ,tlExtremities

44i:LAtANervous system

FEgiNOther abnormal findings

flqfiFx&,tii.EChest X-ray

Exam.(fflt04+86+)(attached chest

X-ray report)

,L 'EK

ECG

4LKEI(TEEffiA&,fi.

ffi6ftF+i2ffiLaboratory

Exam.(HIV, Syphilis

Serodiagnosis )Attached test

Report ofAIDS,

Syphilis etc

*ts-Itr"re.fr r il&)Ett.gprfrtuttj+ .Ar\Mfl{.JtL:tfr ,None ofthe following diseases or disorders found during the present examination.

E il'L Cholera lt )6* Venereal Diseasefi*,rfr Yellow feverffi, )F rtague.ffi Fl Leprosy

JTntWfrfr 4t opening lung tuberculosisJt lM, ;rx'amsi# ?+ )fr Psychosis

' Elfr#+Signature of physician

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