健康检查申请表.docx

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1、健康检查申请表1 HC宁波国际旅行卫生保健中心*NlNGBO INTERNATIONAL TRAVEL HEALTHCARE CENTER健康检查申请表HEALTH EXAMINATION APPLICATION FORM此页资料由申请人提供“。be completed by Applicant姓名 ZName性别/Sex 男/Male 女/Female入境/Entry 出境/Exit 国籍/Nationality 出生 H 期/Birth date婚姻史/History of Marriage 有/Yes 口无/No 职务/Position 证件号码(身份证或护照号Passport or I

2、D No.单位/Name of organizationContact address (China)前往国家或地区/Destination(CountryMistrict)电话/TeL(China)人员类型/Personnel type定居/Immigrant劳务/EmployeeJ I国人员/Chinese back to China涉外婚姻/Transnational marriage其他人员/Others停留时间/Duration of stay 年以下/Less than a year口一年及以 1:/One year or more公务/Officer商务/Business留学/S

3、tudent旅游探亲/Traveler & Visitor交通员 17船员(厨师/木匠)/Transport Staff(CookZCarpenter)从业人员(食储和饮JH水)Food & Drinking water practitioner体检流程/Physical examination process科室/Department楼层及房间号/Floor & Room医生签名/Doctor，s Signature样本采集/Sample collection一楼 107室 the 1, floorftlBlood尿/U line外科/Surgery一楼 112室 the 1, floor眼

4、科、耳鼻喉科Qphth almology ENT一楼 115室 the 1st floor魁检查/BP、P、T、W. H一楼 1。5室 the 1s floor内科/Medicine一楼111室 the 18,fQ0rX 线 X-ray (DR)后楼-楼 122室 the 1 stfloor心电图/ECG楼 114室 the , floor彩色腹部 BffiZB-UItrasound-楼 117/11腔 the 1s, floor1、检查完成清各科室医生崔名.全部完成将检查申清表交网大厅交表窗UDoctors, signatures are needed after exam, hand ov

5、er application form at receiving in the hall after the whole exam2.怀孕女性(需要证明)，避免X线.请将情况提前写在病学!间表上并告知医生State in QUESTIONAIRE FOR MEDICAL HISTORY and inform ckxx ahead, if you are pregnant, avoid x-ray.I T H C宁波国际旅行卫生保健中心NlNGBO INTERNATIONAL TRAVEL HEALTHCARE CENTERQuestionaire for medical history(以下内容请受检人员如实填写,如有疑问请向工作人员咨询)Please fill in the form according to the facts,you could consult the staff if you have any problems