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 Abdomenmune 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