Sh BA tk He Be BE OR FOREIGNER PHYSICAL EXAMINATION FORM see feat | CO bMale | EF A | Name Sex |O & Female Birthday i i EAE ALASLED HE) SESE Present mailing address Photo (Stamped Official (same 1H ia stam) Nationality Bith Blood type (orAsee) lace MAMA Pose: (ESIURT TTI “2” we “HB” Have youever had any of the following diseases? (Each item must be answered “Yes” or “No”) ‘BOS Hj Typhusfever CNo OYes HH] Bacillarydysentery —CINo CiYes “pJuMeRpE Poliomyelitis CINo CiVes — iUGHF Misti Brucellosis CONo Ces Fl Diphtheria =—CONo Yes iH Viel hepatitis CINo Yes iL HH Scarletfever CNo Ves FRILER Puerperal steptococcus infection Im) $3 #% Relapsing fever CINO CYes MER CONo Ces pre HiR —- Typhoid end paretyphoid fever. No Yes EATHEBNYEMOREA Epidemic cerebrospinal meningitis ONo [Yes ESAT PERSIE UREN: (HELM LE OS” ah “IE ) Do you have any of the following diseases or disorders endangering the public order and secuity? (Each item must be answered “Yes” or “No”) atom Toxicomania a, Mental confusion . RiHUR Poychosis. BREA Manic prychosis Ne Yes SEHLN Paranoid peychosis 036%) Hallucinatory- TT DK | Ha Height cM | Weight DRT BH Development Nourishment wh RL. EBD L. tt Vision 4iR. Comected vision 47 R Eyes EH Bee REM Colour sense Skin Lymph nodes ¥ & ane Ears Nose Tonsils > i BL Heart Lungs Abdomenmune WERK at Extemities Nervous sytem Spine Set. Other sbnornal findings ut WR x 8 Ecc ees rea Chest X-ray exam (attached chest X-ray report) Hea te (ease Ces ‘ea FAI PHA) Laboratory exam, (attached test report of AIDS, Syphilis ete) A IESLBAT KV RRBE ES RAGE SS A I: ‘None of the following diseases of disorders found during the present exemination, ata, Cholera ‘ti Venereal Disease igi Yellow fever Meee Lung tiberculosis Plague stu AIDS WA Leprosy RMUR Peychosis eM fete raat Suggestion Official Stamp Ewe? Hitt Signature of physician Date