5b A & #8 & BR FOREIGNER PHYSICAL EXAMINATION FORM. me] UMY HUSA |i lY Male | we | OL > Name “ies eat ad sex [a % Femate| Rinhiny | 7822 | BEAR x Present mating Umuhugar2o@ pmathen Prrracd met] Kayouad me Rhy Nationatity | RYE DAY Binh |p gang | Blood pe (or Area) place HARACA TAM ( SAGHROS “A a 8) Have you ever had any of the following diseases? (Each item must be answered “Yes” or“No") . HES {5% Typhus fever HNo Yes a i Bacillary dysentery AUB Poliomyelitis 4No Yes FECHEI — Brucellosis QR Diphtheria Ho Yes © SHBELLATZE_—Viral hepatitis, No aes {1 HA Scarlet fever No Yes PEAGMALERL Puerperal streptococcus infection (YA WA Relapsing fever GNo oes BR No aes {RAL — Typhoid and paratyphoid fever fINo Yes SRATHERUAHENBLS Epidemic cerebrospinal meningitis ‘ANo Ges ESE MIBRORRIMAENME :(SAERROS “A TR) Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered “Yes” or “No”) Son Toxicomani mee, Mental confusion.. WH Psychosis : BEEN! Manic paychosis. 4)MH Hallucinatory.. ae BK ee Height ATS cM | Weight REBR BAAR BB Development Ve rucrl | Nourishment Noiucok |neck Worn al BA EL Newel | EMT EL AR Vision %R_Algruet | Comected vision 7 R Byes Norm ED BERR eS 0 Coloursense Norural | skin Neoruea? Lymph nodes 0 7402 a mht Br Notuul Noe Notucal Tonsis Aoi al a ® a Han Norcal fins Aur ual | Abdomen A orncer?ORK HERR id Extremities Nervous system | Ny @ 41 Nyrmal FONG FR, » Other abnormal findings | AY 9% © oF OLE p ERX Bcc Norwell team Naaual (nets 2) ‘ ecg Chest X-ray exam C lust x sa (attached chest X-ray report) (eae hate teu “tet Maps brur (ate Stee He SL) S phot: text Laboratory exam ¢ (attached test report of s AIDS, Syphilis etc) ABRIL FSU IE HE RRA HE HE RE ER: None of the following diseases of disorders found during the present examination, / WL Cholera HERR Venereal Disease BEAT Yellow fever BRS — Lung tuberculosis RE Plague Stab AIDS JRE Leprosy HIME Psychosis x Suggestion i Dread St tu Wome hewlh Canmroldh'ou Bema a Signature of physician,