性别
Sex

男Male   □
女Female □

出生日期
Date of Birth

照 片 （盖骑缝章）
Photo
With an indenting stamp of the hospital on the pasted photo

现在通讯地址
Present Mailing Address

血型
Blood
Type

国籍
Nationality  

出生地点/Place of Birth

过去是否患有下列疾病: (每项后面请回答〝否〃或〝是〃)
Have you ever had any of the following diseases
(Each item must be answered Yes or No)

斑疹伤寒 Typhus fever     □ No □ Yes    菌莉 Bacillary dysentery       □ No □ Yes

小儿麻痹症 Poliomyelitis    □ No □ Yes    布氏杆菌病 Brucellosis      □ No □ Yes

白  喉 Diphtheria          □ No □ Yes    病毒性肝炎 Viral hepatitis    □ No □ Yes

猩红热 Scarlet fever        □ No □ Yes    产褥期链球菌 Puerperal streptococcus infection □ No □ Yes

回归热 Relapsing fever     □ No □ Yes     感染 Infection               □ No □ Yes

伤寒和付伤寒 Typhoid and  paratyphoid fever                             □ No □ Yes

流行性脑脊髓膜炎 Epidemic cerebrospinal meningitis                  □ No □ Yes

是否患有下列危及公共秩序和安全的病症:  (每项后面请回答:  〝否〃或〝是〃)
Do you have any of the following diseases endangering the public order and
Security﹖(Each item must be answered Yes or No)
毒物瘾 Toxicomania---------------------------------------------□ No □ Yes
精神错乱 Mental confusion --------------------------------------□ No □ Yes
精神病 Psychosis: 燥狂型 Manic psychosis----------------------□ No □ Yes
妄想型Paranoid psychosis--------------------------------------□ No □ Yes
幻觉型 Hallucinatory psychosis---------------------------------□ No □ Yes

身高                   厘米
Height                  cm

体重                    公斤
Weight                   kg

血压                毫米汞柱
Blood pressure     mmHg

发育情况
Development

营养情况
Nourishment

颈部
Neck

视力   左 L
Vision   右 R

矫正视力         左 L
Corrected Vision    右R

眼
Eyes

辨色力
Color sense

皮膏
Skin

淋巴结
Lymph nodes

耳
Ears

鼻
Nose

扁桃体
Tonsils

心
Heart

肺
Lungs

腹部
Abdomen