Foreigner physical examination form

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FOREIGNER PHYSICAL EXAMINATION FORM

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Name Sex | Female Birthday (‡92S#bHIs)

EAE a Et Photo
Present mailing address (Stamped Official

ElfäEEHU[X uy Ae HH mz Stamp)
. . . Blood type

Nationality Birth
(or Area) place

WHEABS Mem: ( #1IfllEimiRillS“®”5st“K” )

Have you ever had any of the following diseases?
(Each item must be answered “Yes” or “No”}

HH Ú#S Typhusfever No oYes li Bacillary dysentery nNo nYes
Brucellosis nNo nYes
/JVJLRMBTHE Poliomyelitis nNo nYes f#bKHÑA Viral hepatitis ONo oYes
— Puerperal streptococcus
H M& Diphtheria ONo oYes InSMMX infection
nYes nNo nYes
442 21 # Scarletfever No nYes 77 4#8HAHEEX nYes
[=] J Relapsing nNo nYes Re 3X

fever

HEMT Ae Typhoid and paratyphoid fever nNo
JN{TMHMEBEHRZ€ Epidemic cerebrospinal meningitis ONo

ZORA kâ?If&2\RfAIAIS^đl9J7ủ1E : (S11 BiHiRIlSđ5sẩÊ)

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

(Each item must be answered “Yes” or “No”)

I1 Mental TOXỈCOImahia.............(5.-5..5c.cọ.c ..n ..se.s.e ...se .se, nNo nYes
kat! tHOL : ƒR5TU confusỉon..................2.e.<.«.<.5...c.es.s.e.eo nNo nYes ‡Š‡‡j5

Psychosis Manic paychosis.............................5.«.-.-.- ONo oYes 2482

Paranoid psychosÌs.........................--...-.- -.-- ONo oYes

ZJ]3j/l Hallucinatory..................................-.--.-- nNo nYes

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Height CM Weight Kg Blood pressure mmHg

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Development Nourishment Neck

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Vision QR Corrected vision 4 R Eyes

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Colour sense Skin Lymph nodes

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Ears Nose Tonsils

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Heart Lungs Abdomen

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Spine
Extremities Nervous system

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Other abnormal findings

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Ze hes
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(Bie Sits #)

Chest X-ray exam

(attached chest X-

ray report)

(Cis She
(FSSA,
t5 I§ 49)

Laboratory exam

(attached test report
of AIDS, Syphilis etc)

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

= aL Cholera Hi Venereal Disease

fait Yellowfever fipZ4*#% Lung tuberculosis
BEV Plague MJ3MN AIDS
FR IX Leprosy tSHHN— Psychosis

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Official Stamp
Suggestion

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Signature of physician Date