体检表英文模版翻译英文版.doc

Physical Examination Record of XX Township Name: XX Sex Male Date of birth: Jul. 8, 1992 ID No.: XXXX Medical certificate NO.: Servicing unit XX Telephone XX Please provide truthful medical history. The patient himself or herself shall bear any liabilities caused by concealing the facts. (Tick V after each item.). Mental disorder Yes No V Epileptic disease Yes No V Hysteria Yes No V Serious neurosis Yes No V Drug smoking and Yes No V Serious heart attack, Yes No V injecting history cardiomyopathy Chronic nephritis Yes No V Uremia Yes No V Infectious disease Yes No V Nerve system disease Yes No V affecting limb exercise Medical department Blood pressure 120/75mmHg Heart Normal Physician advice: Signature: Respiratory system Normal Abdomen organs Normal Nerve system others Surgical department Height 180cm Weight 77kg Physician advice: Signature: Skin Neck Normal Spine Limb joint Anogenital warts others Eye department Naked vision Right 5.2 Corrected vision Right Color recognition Physician advice: Signature: Left 5.1 Left Eye ground Others ENT department Hearing Left 5 meters Right 5 meters Physician advice: Signature: Cleft lip and palate Smell ENT Others