Physical Examination Record For Foreigner

Male
Name Sex Female Birth Day-month-Year



Present mailing address Blood type
Photo
Nationality Birth Place

Have you ever had any of the following diseases
Each item must be answered YesorNo
Typhus fever NoYes Bacillary dysentery NoYes
Poliomyelitis NoYes Brucellosis NoYes
Diphtheria NoYes Viral hepatitis NoYes
Scarlet ferver NoYes Puerperal streptococcus infection
Relapsing fever NoYes NoYes
Typhoid and paratyphoid fever NoYes
Epidemic cerebrospinal meningitis NoYes

Do you have any of the following diseases or disorders endangering the public order and
security?(Each item must be answered Yesor No)
Toxicomania .................................................................................. NoYes
Mental confusion ... NoYes
Psychosis Manic psychosis .......................................... NoYes
Paranoid psychosis ........... NoYes
Hallucinatory psychosis ... NoYes

Height cm Weight kg Blood pressure

Development Nourishment Neek
L L
Vision R Corrected vision R Eyes

Colour sense Skin Lymph nodes

Ears Nose Tonsil

Hear Lungs Abdomen


Spine Extremities Nervous system

Other abnormal findings

Chest X-ray exam ECG

Laboratory

exam

(Serodiagnosis)

None of the following diseases or disorders found during the present examination
Cholera Venereal Disease
Yellow fever Opening lung tuberculosis
Plague AIDS
Leprosy Psychosis

Suggestion Official Stamp

Signature of physician Date