Sh BA 1k He Be BE Re
FOREIGNER PHYSICAL EXAMINATION FORM
see +451 | 5} Male aE A ir
Name Sex | Female | Birthday Chita ALEC)
Site A at
Present mailing address Photo
‘Stamped Official
sae oc AS ste 7 ene
‘Nationality Birth Blood type is
(or Area) place
SEAL PUB: CARTAN “AR” we RE”)
Have you ever had any of the following diseases?
(Bach item must be answered “Yes” or “No”)
BEE 93% Typhus fever CNo DYes ai $4 Bacillary dysentery CONo OYes
AVURBEE Poliomyelitis. CNo Des — iIGHRYA Brucellosis No OYes
A 9% Diphtheria = (No D1Yes SAREE Viral hepatitis: ONo Des
BL BL fH Scarletfever CINo LiYes PERE Puerperal streptococcus infection
H JH #& Relapsing fever ONo Yes om (No OYes
RRS ‘Typhoid and paratyphoid fever CINo CYes
‘BEFTHERIPAMEIRAE Epidemic cerebrospinal meningitis CINo L1Yes
FEA FER ASIF AU ES MOTTE: (ETT “AR” Be “RL” )
Do you have any of the following diseases or disorders endangering the public order and security?
(Each item must be answered “Yes” or“
NS ‘Toxicomania:
A iaaL Mental confusior
AE Psychosis: MRIEH Manic paychosi
3EMLAY Paranoid psychosis
33641 Hallucinatory
or HD | 1 a | MUR RAE
Height ca | weight Kg | Blood pressure mig
AED ARR a
Development Nourishment ‘Neck
wh £L_____ | hE zL__ |@
Vision 42R, Corrected vision 47 Eyes
Wen Hee wee
Colour sense Skin Lymph nodes
# * mat
Ears Nose ‘Tonsils
a i aie
Heart Lungs Abdomenmune BERR
He Extremities Nervous system
Spine
FEM
Other abnormal findings
Ay HL
AB X Be ECG
ee
i eae aie 4)
Chest Xray exam,
(attached chest X-ray
report)
Net
(ata SaaS
BESTA)
Laboratory exam.
(attached test report of
AIDS, Syphilis ete)
AR BEIERAT FAR IEA REI FSG: BF 23 SR I BEIT:
None of the following diseases of disorders found during the present examination.
RAL ‘Cholera Hes ‘Venereal Disease
HERVE Yellow fever BSHX — Lung tuberculosis
RE Plague St AIDS
JRA Leprosy ABM Psychosis
ez @ eeeip fae
Suggestion
uae aM
Signature of physician Date