自加拿大体检报告书

    Has the applicant used addictive or mood alerting drugs? (Yes or No) 申请人是否服用上瘾药物或兴奋剂？(是或否)

    Does the applicant consume alcohol? (Yes or No, if Yes, How much?) 申请人是否酗酒？(是或否, 如果是, 数量？)

    Does the applicant smoke or has the applicant ever smoked tobacco?  (Yes or No, if Yes, How much?) 申请人是否吸烟或曾经吸烟？(是或否, 如果是, 数量？)

    Has the applicant ever suffered from or been told he had any of the following conditions? (Yes or No)

．Head or neck injury 头部或颈部受伤
．Nose or throat trouble 鼻或喉疾病
．Ear trouble or deafness 耳部疾病或耳聋
．Eye trouble 眼疾
．Chronic cough or asthma 慢性咳嗽或气喘
．Tuberculosis 肺痨
．Other lung disease 其它肺部疾病
．High blood pressure 高血压
．Heart trouble 心脏病
．Rheumatic fever 风湿性热
．Diabetes mellitus 糖尿病
．Endocrine disorders 内分泌疾病
．Cancer or tumor 癌或肺瘤
．Rheumatism, joint or back troubles 风湿性关节或脊背疾病
．Mental disorders 精神病
．Faiting spells, fitsor seizures 突发性眩晕，痉挛或癫痫
．Chronic skin condition 皮肤病
．Stomach pain or ulcer 胃病或溃疡
．Other abdominal trouble 其它肠胃疾病
．Kidney or bladder trouble 肾病或膀胱疾病
．Sexually transmitted disease 性病
．HIV positive 艾滋病阳性反应
．Genetic or Familial disorders 遗传性疾病
．Typhoid fever, malaria, tropical disease 伤寒, 疟疾或热带病
．Operations 曾经动过手术
．Have you ever had a blood transfusion 曾经接受输血
．Is the applicant now taking any medication or receiving treatment which must be continued in the future?(Yes or No) 申请人是否正在服药或要继续治疗？(是或否)

    Please elaborate on all "yes" answers of questions include significant dates and know treatment.对以上回答“是”的问题请详细说明, 包括治疗日期.

    Physical examination to be completed by the examining physician.体格检查, 由检验医生完成本报告.

    Upon medical examination are there any abnormalities of the following: 体检中是否发现以下不正常的情况:

．Head and Neck 头和颈部
．Mouth and throat 口腔和喉部
．Ears 耳
．nose 鼻
．Eyes including fundi 眼睛包括眼底
．Heart 心脏
．Chest, lungs and breast 胸, 肺和乳房
．Abdomen, liver, spleen,etc. 腹部, 肚, 脾等
．Genito-urinary system 泌尿生殖系统
．Hernial sites 疝气
．Extremities and spine 脊柱和四肢
．Nervous system 神经系统
．Skin including surgical scars 皮肤包括手术疤痕
．Lymphatic system 淋巴系统
．Evidence of mental abnormality 精神病症状
．Any other abnormalities 其它不正常情况
．Female applicant pregnant if yes, date of L.M.P. 女申请者是否怀孕？如是, 注明最后月经日期
．Is the applicant now taking medication or receiving treatment of any kind? If so, specify

    申请人目前是否服用药物或接受其它治疗？如是,请说明

Height 身高