Sh BL A HR Ht Re BE #8 FOREIGNER PHYSICAL EXAMINATION FORM ih gow | OMe | auerLaR FUE Name Sex | Female | Birthday (mmateeete mene) SELES Present mailing address Photo [ ie Tee fot (Stamped Official Petes x mas Stamp) Nationality, Birth Blood type (or Area) place | MEARE see: CAESIUENT IRE “7” “IR”) Have you ever had any of the following diseases? (Bach item must be answered “Yes” or “No”) | HES Yj Typhus fever CINo ClYes a 3H Bacillary dysentery No D1Yes ASJLIRGEIE — Poliomyelitis [No [Yes WEG HGT Brucellosis No OYes 4 — Diphtheria CINo (Yes ‘WHIEVERFH — Viral hepatitis No Des AL fh Scarlet fever No Dyes EMER Puerperal streptococcus infection fl WH #4 Relapsing fever LINo (Yes: aah CINo LYes Pi R ANS GME Typhoid and paratyphoid fever OONo OYes ‘ETT HENTAI — Epidemic cerebrospinal meningitis. No Yes EGBA TELAT N EERE: (ESRI “A” ak 2” ) ty 8 wraL, CT Hifi Psychosis: (Each item must be answered “Yes” or “No”) Toxicomania Mental confusion BREEN — Manic psychosis: %EHNAY Paranoid psychosis“ Xy36A1— Hallucinatory: Do you have any of the following diseases or disorders endangering the public order and security? ae nO | fat ane | MUR ORE Height cM | Weight Ke | Blood pressure mmHg | serene BIR E ai Development Nourishment Neck wh BL EWA EL. To Vision 47 R a Corrected vision 47 R. Eyes we) | ei we Colour sense Skin Lymph nodes ¥ 2 | aR Ears Nose “Tonsils & th : ‘i Heart Lungs ‘Abdomen] Wa cd FRE Extremities ‘Nervous system Spine SBT, Other abnormal findings pitts ai x ECG Re (ibe ak Y) Chest X-ray exam (attached chest X-ray report) Hess itt (eal SER. sa ML PAA) Laboratory exam (attached test report of AIDS, Syphilis ete) RBG FABER ATIE HE ASEH BERR: "None of the following diseases of disorders found during the present examination. Wis, Cholera HIN —Venereal Disease BLANKIE Yellow fever ASHE Lung tuberculosis HE Plague StH AIDS. WRI Leprosy MIME Psychosis xe -@ ete Mica ie Suggestion Official Stamp ee i) Signature of physician Date L