629 [ PDE yICC Sh BLA 1K Hie A oe Ae FOREIGNER PHYSICAL EXAMINATION FORM eh ‘Name TUN sex | deFemale | Birthday GUE NAHE! Het | OR Mote | EEA Lay, mm Nat Present mailing address anes Het (or Area) place SLC UM HE DINH be \ one Wane sm [orm Se] st at ARMIN F DM: CemMTNENT “BH” HE Have you ever had any ofthe following disea iw (Exch item umst be answered "Yes" of "No") S24 SUE HR Typhusfever GNo Ove I _Bacillay dysentery No ves A> JLIESE — Poliomyelitis fANo LlYes WATT =— Brucellosis EINo LYes a = Diphtheria No Oves ‘iREMES Viral hepatitis GINo Oyes @ 9% Scarletfever [No Dyes PVGMEEER — Puerperal streptococcus infection JH #4 Relapsing fever (No Yes aR (No Oyes ‘GARTH Typhoid and parayphoid fever EINo Di¥es ETHERUTFRAREE Epidemic cerebrospinal meningitis GINO CIYes RASA HERA OES he: (Mame “A” ok “Re” ) ‘Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered "Yes" or “No") eS ‘Toxicomania HAL ‘Mental confusion UR Psychosis: BEES Manic paychosis EM Paranoid psychosis 436% — Hallucinatory- a me | fe a | lk DRE Heist 165 cm | weit 5G Ke | Blood pressure 2/60 nmtia RAR THR it 1 Development ‘Nowishment Neck wn #zL_Z4140 | EM #L_Afdo | me : Vision #@R__< {do | Comected vision #R_ACHO | Eyes Mpopia: WEA ca REF Cotoursense — Moma | sein Normal — | rymph nodes — eine L % r _ aE cs 8 eins! AB. Plame | Te Neral e C7 mie fe Nai | Frogs Nocmel | ardomen NawalSpine Newer £ | L ni — pall eee SOF Cer abort fintings | oe AEX ECC eR (nteestem gem) pomal Noenel (Chest Xray exam (amached chest Xray report) Hs. tesa te ut (Estas. un ‘ete Sune te) thin Laboratory exam (attached tes report of| AIDS, Syphilis etc) & rey FR ATLLAT F RRA REARS SBE TE: ‘None ofthe fllowing diseases of disorders found during the present examination. py eal, ‘Cholera em ‘Venereal Disease HRIRA Yellow fever BER Lung ruberculoss IE Plame ‘tite aus FRI Leprosy RAE Poytoss ge Suggestion Goved Real the wana ‘Signature of physician