7/30/2019 Physical Examination Certificate in SHZU

1/2

FOREIGNER PHYSICAL EXAMINATION FORM

Name

Sex

Male Female

Birth Day-Month-Year

Photo

(stamped

Official Stamp)

Present mailing address

Blood

Nationality

Birthplace

Have you ever had any of the following diseases?

(Each item must be answered YesorNo)

Typhus Fever NoYes Bacillary Dysentery NoYes

Poliomyelitis NoYes Brucellosis NoYes

Diphtheria NoYes Viral Hepatitis NoYes

Scarlet Fever NoYes Puerperia Streptococcus infection

Relapsing Fever NoYes NoYes

Typhoid or Paratyphoid Fever NoYes

Epidemic Cerebrospinal Meningitis NoYes

Do you have any of the following diseases or disorders endangering the public order and security?

(Each item must be answeredYesorNo)

Toxicomania ..NoYes

Psychological Disorder ..NoYes

Psychosis: Manic Psychosis NoYes Paranoid Psychosis.NoYes

Hallucinatory Psychosis ...NoYes

Height cm

Weight kg

Blood pressure mm Hg

Development

Nourishment

Neck

L_____

Vision R

L_____

Corrected vision R

Eyes

Color Sense

Skin

Lymph Nodes

Ears

Nose

Tonsils

Heart

Lungs

Abdomen

7/30/2019 Physical Examination Certificate in SHZU

2/2

Spine

Extremities

Nervous System

Other abnormal findings

X

Chest X - ray

exam

(attached chest

X - ray

report)

ECC

Laboratory exam

(Attached test

report of AIDS,

Syphilis, etc.)

None of the following diseases of disorders found during the present examination

Cholera Venereal Disease

Yellow Fever Lung Tuberculosis

Plague AIDS

Leprosy Psychosis

Suggestion Official Stamp

Signature of Physician Date