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对上述项目进行了检查

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检 查 内 容

Physical examination and Chest X-ray 身高(Height)

cm

体重(Weight) Kg

血压(Blood Pressure) / mmHg

胸部X射线检查日(Date of Chest X-ray) / / I. 结果(1) (Result):

1. 非特異所見(Non-specific) □ 2. 非活動性結核(Inactive TB) □ 3. 活動性結核 (Active TB) □

→ 3-1. 傳染性(Infective) □, 非傳染性(Non-infective) □

→ 3-2. 感受性結核(Drug-sensitive TB) □, 多劑耐性結核(MDR TB)

II. 治療结果(2) (Treatment Outcomes) - For person who has TB history 1. 治療中(Under treatment) □,

2. 完治(Cured) □

3. 完了(Completed Treatment) □ 4. 治療失敗 (Failed) □

5. 治療漏落 (Defaulted) □

对上述项目进行了检查

The examination was performed as above.

执照号码(License No.)

: /

医生姓名(Name of Physician)

: (

签章

)

检 查 结 果

(Summary of the examination)

对受检者停留的意见

(Remarks about examinee’s domestic stay)

仔细检查的必要性

(Additional close examination)

*

若必要时补充医生的意见书

(Attach doctor's opinion letter, if needed)

以上是对受检者健康状态的结果与评估。

We hereby certify that the examinee's heath status is assessed as above.

dd.mm.yyyy.

○○○○

医院院长

(

印章

)

( ○○○○ Chief of Hospital) (signature)

健康诊断书

Certificate of Health (Photo)

照片

3㎝×4㎝

※钢印或骑缝章

姓名(Name) 性别(Sex)

□ M(男) □ F(女)

出生日期(Date of Birth) 电话号码(Phone Number)

护照号码(Passport Number) 地址(Address)

참조

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