FOREIGNER PHYSICAL EXAMINATION FORM
			OH Male				HS tir
Name		Sex	OjČC Female		Birth Day - Month - Year		
							
Present mailing address						ŇLM Blood type	Photo
Nationality (or Area)		Birth Place					( stamped Offical Stamp)
Have you ever had any of the following diseases? (Each item must be answered "yes" or "No")
$£ & ffi ^   Typhus fever          LJNoDYes 0 $J
'WL$$říĚ   Poliomyelitis          DNoDYes IpfcffWk
Ď                 Diphtheria             DNoDYes ^#'l4fFife
I   IT   *   Scarlet fever          □ Nod Yes ^#l$]ÍSí£
HI   Íl3   íft   Relapsing fever      □ NoLJYes m   !& tk {Jj^fflfťfíjS   Typhoid and paratphoid fever ^ÍT'&ffiWlitJ$l:ífe   Epidemic cerebrospinal meningitis
Baciilary dysentery DNoLJYes Brucellosis DNotJYes Viral hepatitis □ Nod Yes
Puerperal streptococcus infection □NoLJYes
□NoDYes □NoLJYes
Do you have any of the foUowing diseases or disorders endangering the public order and security?
(Eahe item must be answered "yes" or "No")
Toxicomania ........................•..............•...................................... DfvoQYes
fSW^h^L   Mental confusion ...........-..............-.......•.................................. CjNoLjYes
%nffi'M   Psychosis               Manic Paychosis ................................................ □ NoDYes
ilcSM   Paranoid psychosis .......................................•........ j_!NoDYes
£73&§y   Hallucinatory psychosis •■■....................................... U NoLJYes
Height CM	Weight kg	Blood pressure mmHg
Development	Nourishment	Neck
Vision           ~fo r	mjEUji     £ l Corrected vision r	PS. Eyes
Colour senes	Skin	Lymph nodes
Rars	& Nose	HW Tonsils
>ú Heart	w Langs	to Abdomen
# a
Spine
Extremities
Nervous system
Other abnormal findings
Chest X - ray exam ( attached chest X-ray report)
ECG
Laboratory exam (Attached test
report of AIDS, Syphilis etc)
None of the following diseases of disorders found during the present examination.
IB   j§l   Cholera Üt Venereal Disease
Yellow fever Ifc^r^   Lung tuberculosis
K   £   Plague %UM
M   Leprosy fäffifä Psychosis
Suggestion Official Stamp
Signature of physician
Date