RDI-B, T ij aoe Paleistavy SEAGATE: CETL “25” Have you ever had any of the following diseases? we “R") (Each item must be answered “Yes” or “No”) HEE HI BNo Dyes ‘Typhus fever w 3H Bacillary dysentery No DYes AUS Poliomyelitis Zo CYes i GAFIMIYM| Brucellosis. No OYes al %R Diphtheria (No Ges SHIEHENEDE Viral hepatitis No Dyes MW @ # Scarlet fever No Des F=VBNIGEER — Puerperal streptococcus infection JA #& Relapsing fever ZINo Des wm the Oyes MRAM GR Typhoid and paratyphoid fever ZINo ChYes HETHEMAFMAEA — Epidemic cerebrospinal meningitis No OYes BEE MATT USERS Ade MAME = (EBT A Do you have any of the followi (Each item must be answere: Wenn Toxico mira, Mental c HMR — Psychosis: YEH me") diseases or disorders endangering the public order and security? fes” or “No") a sonfusion:**~ Manic paychosis" (No Byes 4H Paranoid psychosis: r No OYes XINEH — Hallucinatory~ No Oves mK | Heat am | se BOAT ” Se ca veer 1D. ta | Shovyann [70 ante Bvt C j | WretihR Cae: Bis ‘ Development 22) gt Nourishment CVILZ C ‘| Neck 47’ ) mA BL, BRERA EL LUE Va Vision #R_E i Corrected vision 43 RAZ "| eyes 1) HOA BK WO Colour sense Skin Lymph nodes y R We ee ptt). | Nox HAT) \renste wtf? wb a bin ‘Heart Lungs Abdomen(tases tikes ‘EME OF nN 7H te) Laboratory exam (attached test report of AIDS, Syphilis etc) ARRAS EDAD BE est A106 HE EI None of the following diseases of disorders found during the present examination. 4H Cholera tes Venereal Disease BIA Yellow fever Wishit& — Lung tuberculosis ME Plague sti AIDS RR, Leprosy HEH — Psychosis gli ees he 1. / bpd Official Stamp, =