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FORETGNER PHYSICAL EXAMINATION FORM

!*fi fVlur-hcr-rn 'rnall ,t&ElJ dH Male S4HH 2s -1-l*)

Name
'(t!.qas
T Sex a* Female Birthday

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V tltaqgTointi dr'St-t,ct T*nk
Prqsent mailing address
Pasl oh"tcP 6tt( f+a"r't ru

trffr4Jetr s elu m4
Nationality
(or Area)
PrvKi.St-nn Bilth
place
k'nk Blood type
n
+
t,
jS*-EAEATF4E'1fi, (€rrtrffiitrElE "6" E\, "8" tcQ tOffic*
Have vou ever had any of tl-re folloti,ing diseases?
(E,ach item must be ausrverecl "Yes" or"'No") h, uu**:
*rr1..,i*,i.

TILD tfix Typl.rus fever ilNo

nYes H#f dysentery BNo EYes
Bacillary
d') LF,UFtr Poliomyelitis MNo nYes frftfrH,ffi Bruccllc,sis ilNo nYes
E tt* Diphtheria fll5o LlYes ,fi€,1*xf4. Viral hepatitis MN<, EYcs
dE Lt' +lt, Scarlet t-evel MNo IYes PiEHf$lt Puerperal stl'eptococor.rs inf-ectiou
E r)t #l Relapsing l-ever MNo trYes Hl** dlNo L-.lYes

(fi*frntttfrx /'
Typhoid and paratyphoid fevel rENo nYcs
i,if lleflfr#fiElH4 Epidemic cerebrospinal meningitis XYes

E6,H&'TftJfuN-]A+\fikFttr?+Fjl'ffitr' (ErftrEi#E$ "6" 4 "8" )

Do you have any ofthe lbllou,ing diseases or disorders endangering the publio order and securitl,?
(Each item must be answered "Yes" or "No")
#VJ[h, Toxicomania.' .'ZNo DYes
)f6ilt#fL Mental con1lsion...... .........dNo IYes
)fE#)fi Irsy'chosis: EjfttrI4 Manic paychosis.....'........ ........UNo nYes
*igfl Palanoid ps1,chosis""" '...........ZNo EYes
nffil/ Hallucinatory,. .....MNo IYes
,f+E iirE ,blro €Xrx-fi
3.h, ffit"w E# Weight s-g ^fr
Kg B loocl pressure mmFIg

ftHf#fi t ,. H#tHin ,F*n

Developmert Yl eo
( il^tX
Nourishment H ee(.tw Neck Ncrn"('
+Mr E a b
ile
trtE&)J EL- fE
Vision En Corrected vision f R_ Eyes Nawncrl
*fre)i ol Ent sfiE#
Colour sense

4
1C Skin rl#d/ Lymph nodes

ffittL[E
Nit(,

Ears No-rrn.'( Nose Tonsils Nttt

,[. flfr E*ll
Heart No"tgv'A Lungs f4\$ *-O Abdomen Nfi{tuLg
 Erffi t+4Rgi
i5& Extremities Nervous system
Spine Not tndu fJOmnrrL Inip*t
X{,t,,FfiF,
Other abnormal findings

,tl'E El
fl@#[x& ECC
thtr#x
(pfffe€ffi#+) ^n
LVcaz c0ea-t
Chest X-ray exam
(attached chest X-my
report)

4L&Bfed
(Effiti#ffi.
*EE6+m.iH+&E)
Laboratory exam f.lttt",
(attached test report of
AIDS, Syphilis etc)

*.44 ffi a-F v tJ&E[+" Wrfr ffifr$ /* X@H F0 )Erff :

None of the following diseases of disorders found during the present examination.
EfrL Cl.rolera 't4,ffi Venereal Disease
!tt&,ffi Yellorv fever' Efr'+-"M Lung tuberculosis
tsu,,iE Plague {i#)fi AIDS
ffiX Leprosy
h )f#irF)fi Psychosis

n &trB.fn#H
Suggestion
fiL Official Stamp

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Signature of fi$.,t 3* le*&ozz