健康检查申请表.docx

1、健康检查申请表名卜C宁波国际旅行卫生保健中心MmoaoWTTOunOMMmwvtMKMnCAAfcom*健康检查申请表HEALTHEXAMINATIONAPPLICATIONFORM此页资料由申请人提供“ObempletdbyApplicant姓名/Name性别/Sex男/Male女/Female入境/Entry出境/ExitL14/Nationality出生IlWUBirthdate婚明史/HistoryofMarriageYsNom分/Position证件，码(少份证或护照与VPassportorIDNo.i(NamoforganizationMUitZContactaddress(Chi

2、na)rt往国家或地l*DestinatiOn(COUntry/district)电话/TeL(China)人员类型/Personnel type定用/Immigrant劳务正mployeeV IIflAMZChinese back to China:涉外婚WnVansnational marriage停留时间QUrationofstay一年以E/Lessthanayear一尔及以I：/Oneyearormore公务/Officer商务/Businessfit学/Student旅游探亲/Traveler&Visitor交通员ltd(WW体匠)ranspo11Staff(CookZCarpent

3、er)从业人员(食初饮用水)Food&DrinkingwaterpractitionerKftfeAMOhers体检流程/PhysicalexaminationprocessH室/Department楼乂及坊间号/Floor&Room国小注片DoctorsSignature样本果US/Samplecollection-l7S(te1*fkor血/Blood尿/Urine外科/Surgery楼112therfloor眼科、If显喉科/OPhthaknologyENT楼115室theIMftoOr依检杳BP.P.T.W.H楼105室the1ftoor内科ZMediCine楼ill室te1floor

4、X线X-ray(DR)后楼楼122室the1-floor心IIIra正CG-楼114号the1fkx)r彩色履部B超/B-UHraSOUnd楼I17ll8therfloor1 .梭件之成i各科室国小答名.全部完成将松杳申请表交Hl大厅交表窗UDoctorssignaturesareneededafterexam,handoverapplicationformatreceivinginthhallafterthewholeexam2 .怀牛女性(需要证明),避免X线,好将情况提前。住制”询问我上并告知快生StateinQUESTIONAIREFORMEDICALHISTORYandinfoffndoctorahead,ifyouarepregnant,avoidx-ray.1咸宁波国际旅行卫生保健中心FvrmngoMtvrmatxmalTMmMrAtTxAMCtwrtRQuestionaireformedicalhistory(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)PleasefillIntheformacrdingtothefacts,youcouldconsultthestaffifyouhaveanyproblems