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FOREIGNER PIIYSICAL EXAMINATION FORM

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Name Sex tr f Female Birthday m#&Ë+.{üÉpË)

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Present mailing address Photo
(Stamped OIÏicial
E,ffiütutr $&iü fr.4 Stamp)
Nationality Birth Blood type
(or Area) place

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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
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Do you have any of the following diseases or disorders endangering the public order and security?
(Each item must be answered "Yes" or "No")
æryJM Toxicomania üNo trYds
*âTFffiÉL Mental confusion"" ENo EYes
*Ë+FrË Psychosis: Bflfie Manic psÿcho-sis:""" f]No flYes
Ëf§e Paranoidpsychosis"" ENo flYes
k1H,4. Hallucinatory ENo EYes

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Height CM Weight ^rî
Kg Blood pressure mmHg

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Development Nourishment Neck

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Vision Ë R----- Corrected vision Ë R.- Eyes

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Colour sense Skin Lymph nodes

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Ears Nose Tonsils

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Heart Lungs Abdomen
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ëfi Extremities Nervous system
Spine

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Other abnormal findings

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ffiËrxâ BCG
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(pftfûËffi#ë)
Chest X-ray exam
(attached chest X-ray
repod)

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(@rÉËiâ)ffi.
f&Ësmffi+fûa)
I, aboratory exam
(attached test report of
AIDS, Syphilis etc)

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None of the following diseases of disorders found during the present examination.
æfrL Cholera {!L)Ë Venereal Disease

ËLe)ffi Yeliow fever frfr4âth, Lung tuberculosis

ffi,Æ Plague Ïi#rË AIDS
ffi,Et Leprosy )fË,TF)Ë Psychosis

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Suggestion Offrcial Stamp

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Signature of physician Date