【붙임1】건강진단서

健康诊断书 Certificate of Health		照片 (Photo) 3㎝×4㎝ ※钢印或骑缝章
姓名(Name)	性别(Sex) □ M(男) □ F(女)
出生日期(Date of Birth)	电话号码(Phone Number)
护照号码(Passport Number)	地址(Address)

检     查     内     容

Physical examination and Chest X-ray or ooooo

身高(Height) cm	体重(Weight) Kg	血压(Blood Pressure) / mmHg
胸部X射线检查日(Date of Chest X-ray or ooooo) / / I. 结果(1) (Result): 非特異所見(Non-specific) □ 非活動性結核(Inactive TB) □ 活動性結核 (Active TB) □ → 3-1. 傳染性(Infective) □, 非傳染性(Non-infective) □ → 3-2. 感受性結核(Drug-sensitive TB) □, 多劑耐性結核(MDR TB) II. 治療结果(2) (Treatment Outcomes) - For person who has TB history 治療中(Under treatment) □, 完治(Cured) □ 完了(Completed Treatment) □ 治療失敗 (Failed) □ 治療漏落 (Defaulted) □

对上述项目进行了检查。

The examination was performed as above.

执照号码(License No.):           / 医生姓名(Name of Physician):            (签章)

检 查 结 果 (Summary of the examination)
对受检者停留的意见 (Remarks about examinee’s domestic stay)
仔细检查的必要性 (Additional close examination)	* 若必要时补充医生的意见书 (Attach doctor's opinion letter, if needed)

以上是对受检者健康状态的结果与评估。

We hereby certify that the examinee's heath status is assessed as above.

dd.mm.yyyy.

○○○○医院院长     (印章)

( ○○○○ Chief of Hospital)   (signature)