Name of physical examination hospital: physical examination date: year month day
Last name, gender, date of birth
Small 2 inches bareheaded recent photo.
Physical examination unit riding seal
workplace
aboriginal
memory
Family calendar
Outside
Signature of Thyroid Spine Physician:
Wet limbs
Anal hilar joint
apparatus urogenitalis
Chita
inside
Signature of blood pressure doctor:
Nerve and spirit
Lung and respiratory tract
Heart and blood vessels
Abdominal organ liver
spleen
Chita
Signature of chest X-ray radiologist:
Signature of ECG doctor:
Signature of Laboratory Technician of Hepatitis B Surface Antigen for Transaminase:
five
police officer
Subject's vision is right, corrected vision is right, and signature of other ophthalmologists:
Left, left.
Hearing right ear disease
left
Diseases of nose and paranasal sinuses
throat
Chita
owner
check
knot
Results (Please mark the following parts with "√" on the qualified items)
Results: 1, healthy 2, average or weak 3, chronic disease.
(If you have chronic diseases, please continue to tick "√" on the following items)
1. Cardiovascular diseases. tuberculosis
2. Cerebrovascular diseases. diabetes
3. Chronic respiratory diseases. Neurological or mental illness
4. Chronic digestive diseases. Other chronic diseases (specific):
5. Chronic nephritis
Medical examination hospital seal
Signature of Chief Examiner: Date: MM DD YY.
be filled/suffused/brimming with
Opinions of the registration authority
Seal of registration authority
Completion date: year month day.
Note: 1. Please fill in the contents of the form truthfully and neatly, and do not alter or forge it.
2. After the physical examination, this form should be submitted to the registration authority.
Please stick the X-ray, ECG and liver function report on the back.