Physical examination report in English blank formTHE HEALTH EXAMINATION REPORTOF YANGQUAN SECOND PEOPLES HOSPITAL Name Gender Born Marital Status Education Nation Occupation Address work unit

THE HEALTH EXAMINATION REPORT OF YANGQUAN SECOND PEOPLE'S HOSPITAL

Name: ____________________________________________________________ Gender: ____________________ Born: ________________________________ Marital Status: ____________________ Education: _____________________ Nation: ____________________ Occupation: __________________________ Address: __________________________________________________________ Work Unit: ________________________________________________________

Anamnesis: ENT: Eyes: Eyesight L: ____________________ Eyesight R: ____________________ Contact lenses L: ____________________ Contact lenses R: ____________________ Color blindness: ____________________ Eye disease: ____________________

Ears: Hearing L: ____________________ Hearing R: ____________________ Ear disease: ____________________

Nose: Sense of smell: ____________________ Nose disease: ____________________

Throat: Oral: Lip and palate: ____________________ Teeth: ____________________ Facial: ____________________ Other: ____________________

Surgery: ____________________

Height: ___________ cm Weight: ___________ kg Skin: ____________________ Lymph: ____________________ Thyroid: ____________________ Spine: ____________________ Limbs: ____________________ Joint: ____________________ Flatfoot: ____________________ Other: ____________________

Internal Medicine: Blood Pressure mmHg: ____________________ Pulse Rate / min: ____________________ Development and nutrition status: ____________________ Nervous and mental: ____________________ Lung and respiratory: ____________________ Heart and vessels: ____________________ Abdominal organs: Liver: ____________________ Spleen: ____________________ Other: ____________________

Chest radiography: ____________________

Signature of Doctor: ____________________ Review comments: ____________________ Signature of Review Units: ____________________ Remarks: ____________________ Date: ___________________