Name, age, sex, married or not, country photo.
Contact telephone number of native place and current residence
Past medical history (truthfully filled in by myself)
Right correction of naked eye vision and the degree of right correction of vision in otolaryngology department. Right doctor's opinion: signature:
the left side
Color-discriminating ophthalmopathy
Hearing left ear meter and right ear meter
Nose, olfactory nose and sinuses
Face and throat
Oral labial palatine teeth
other
Surgical height cm weight kg Physician's opinion: signature:
Lymphatic spine
Limb joint
Skin neck
other