女性婚前医学检查表.doc

女性婚前医学检查表(外国人、港澳台居民、居住在国外的中国公民)PremaritalMedicalExaminationforFemale(CitizenofOthercountries,ChineseCitizenResidingOutsideMainlandChina(includingHongKong,MacaoandTaiwanorOtherCountry))填写日期(DateofForm-filling):___月(M)___日(D)___年(Y)近期一寸姓名(Name)____________________免冠正面出生日期(DateofBirth)___月(M)___日(D)___年(Y)照片加盖职业(Occupation)_____________文化程度(Education)_________婚检专用章国籍(Nationality)_____________出生地(PlaceofBirth)____________民族(Race)_________________________身份证或护照号(IDorPassportNo.)现住址(PresentAddress)____________________________________________________邮编(Postcode)_______________工作单位(Unit)_______________________________________________________电话(TelephoneNo.)_______________对方姓名(NameofthePartner)________________---------------以下由医生填写(Thefollowingwillbefilledbythemedicalstaff)-----------------编号(SerialNumber)______________对方编号()___________检查日期(DateofExamination)______月(M)_____日(D)______年(Y)血缘关系(BloodKinship):无(No),表(Cousin),其他(Other)_________过去病史(PastDiseaseHistory):无(No),心脏病(HeartDisease),结核(TB),肝脏病(LiverDisease),泌尿生殖系疾病(UrogenitalDisease),糖尿病(Diabetes),高血压(Hypertension),精神病(MentalDisease),性病(VD),冶游史(VisitProstitutes)癫痫(Epilepsy),甲亢(Thyroidism),先天疾患(CongenitalDisease)_____________________________,其他(Others)___________________________________,手术史(OperationHistory):无(No),有(Yes)_______________拒答(Refusal)现病史(PresentDiseasehistory):无(No),有(Yes)______________