[PDF] ?1 ts^/#ffi&.?? gID ifrX Typhus fever nNo [

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ÿ1 ts^/#ffi&.ËË

FOREIGNER PIIYSICAL EXAMINATION FORM

Name ,[45U

SexD E Maletr f Femaleü4 EH

Birthday

f,(H m#&Ë+.{üÉpË) Photo

Stamp)

WAEl,:R,jüft

Present mailing address

E,ffiütutr

Nationality

(or Area) $&iü Birth place fr.4

Blood type

ü*Ëâ,HÉTttJffffi, (@4trÉiËEae "6" ü "ft")

Have you ever had any of the foliowing diseases?

(Each item must be answered "Yes" or "No") gID ifrX Typhus fever nNo [Yes Ë ffi Bacillary dysentery trNo nYes /J,)Lffiffitr poliomyetiris DNo nYes 7FÉfrËrË Brucellosis trNo trYes E ÿ& Diphtheria ENo EYes )ËëËnT Viral hepatitis nNo EYes

4E ,: fl1 Scarlet fever ENo EYes Êil$Hâ$r'* Puerperal streptococcus infection

EI ÿl #l Relapsing fever flNo nYes Ë ffi * nNo EYes th&îfr{tlfrX Typhoid and paratyphoid fever trNo trYes iô{T'EnÙi5ËËnË^. Epidemiccerebrospinalmeningitis nNo trYes *Ë+FrË Psychosis: Bflfie Manic psÿcho-sis:"""

Ëf§e Paranoidpsychosis""

k1H,4. Hallucinatory Ëâ.ffiê-TfüÉ,X^XfrXffiffiËàfrt1ffiË, (@4ËffiiËEae u6" ü "Ë" ) Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered "Yes" or "No") aeryJM ToxicomaniaüNo trYds

ENo EYes

f]No flYes

ENo flYes

ENo EYes

*âTFffiÉLMental confusion""

9H tr)KHeight CM,f+É ^rîWeight Kg.m.E ë)K*&

Blood pressure mmHg

ÊËtËix,

Development

ËaetËïE

Nourishment

,a*F Neck

4flj1 Ë L-

Vision Ë R-----ffiÉtMJ EL-

Corrected vision Ë R.-

HE Eyes

ÿfr8i1

Colour sense

Éffi

Skin iffis#

Lymph nodes

s Ears )f Nose ffidh,{4

Tonsils

Heart trtr Lungs Effi

Abdomen

ëfi

Spine

EËT

Extremities

14t41"91,

Nervous system

NfiÜ,Ffrfr

Other abnormal findings

ffiËrxâ&É#* (pftfûËffi#ë)

Chest X-ray exam

(attached chest X-ray repod) ,ù'ÉEl BCG

4rsûËfûË

(@rÉËiâ)ffi. f&Ësmffi+fûa)

I, aboratory exam

(attached test report of

AIDS, Syphilis etc)

* frrAE, H â' T rü tt É.É wffi ffi fr,* â\ Jt{ÉAE É! ;È )ffi : None of the following diseases of disorders found during the present examination. aefrL Cholera {!L)Ë Venereal Disease ËLe)ffi Yeliow fever frfr4âth, Lung tuberculosis ffi,Et Leprosy )fË,TF)Ë Psychosis

Ënl

Suggestion

tôê+,fü#Ë

Offrcial Stamp

tr,ÿfiae+

Signature of physician

HH Datequotesdbs_dbs24.pdfusesText_30

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