健康诊断书样式-韩国驻武汉总领馆

照片(Photo)3㎝×4㎝性别(Sex)□M(男)□F(女)※钢印或骑缝章身高(Height)体重(Weight)血压(BloodPressure)cmKg/mmHg检查结果(Summaryoftheexamination)对受检者停留的意见(Remarksaboutexaminee’sdomesticstay)仔细检查的必要性(Additionalcloseexamination)以上是对受检者健康状态的结果与评估。姓名(Name)出生日期(DateofBirth)电话号码(PhoneNumber)PhysicalexaminationandChestX-ray检查内容【附件】检查日(DateofChest)//1.胸部X线检查□2.痰结核菌检查□3.结核菌素试验□4.血液检查□非特异所见(Non-specific)□非活动性结核(InactiveTB)□护照号码(PassportNumber)地址(Address)健康诊断书CertificateofHealth→3-1.传染性(Infective)□,非传染性(Non-infective)□→3-2.感受性结核(Drug-sensitiveTB)□,多剂耐性结核(MDRTB)○○○○医院(印章)dd.mm.yyyy.Weherebycertifythattheexaminee'sheathstatusisassessedasabove.执照号码(LicenseNo.):/医生姓名(NameofPhysician):(签章)对上述项目进行了检查。Theexaminationwasperformedasabove.治疗漏落(Defaulted)□II.治疗结果(2)(TreatmentOutcomes)-ForpersonwhohasTBhistoryI.结果(1)(Result):活动性结核(ActiveTB)□治疗中(Undertreatment)□,完治(Cured)□完了(CompletedTreatment)□治疗失败(Failed)□