Surname name

name

Gender

SEX

□ MaleMale

□ GirlFemale

Date of birth\

BIRTH Day-Month-year

Photo Film

(Covering inspection

Unit seal)

Photo

(Stamped

Office Stamp)

Now communication address

Present Mailing Address

Blood type

blood

Type

Country Nationality

Nationality

birth address

BIRTH PLACE

Whether to suffer from the following diseases in the past: (Please answer "Sky Bet app " or "Yes")

Have You Ever Had Any of the Following Sky Bet app ?

(Each item must be antswered "yes" or "Sky Bet app "

SpotsrashTreatment of typhoid fever Typhus Fever □√Sky Bet app □Sky Bet app bacteria Diabang Bacillary DySensery □√Sky Bet app □Sky Bet app

PuThe paralysis Poliomyelitis □√Sky Bet app □Sky Bet app Bacteria disease BRUCELLOSIS □√Sky Bet app □Sky Bet app

White throat Diphtheria □√Sky Bet app □Sky Bet app viral hepatitis Viral Hepatitis □√Sky Bet app □Sky Bet app

Gorilla Red Hot Scarlet Fever □√Sky Bet app □Sky Bet app Chain ball during puerperium Puerperal Streptococcus Information

Back Return Hot Relapsing Fever □√Sky Bet app □Sky Bet app bacteria Feel Dye □√Sky Bet app □Sky Bet app

Treatment of Typhoid and Pic. Typhoid and Paraatyphoid Fever □√Sky Bet app □Sky Bet app

Popularic cerebral grsoneitis Epidemic Cerebrospinal Meningitis □√Sky Bet app □Sky Bet app

Do you have the following diseases that endanger public order and security: (Please answer "Sky Bet app " or "Yes")

Do you have any of the Sky Bet app illases or DISORDERS ENGERING The Pubic Order and Security?

(Each item must be angred "yes" or "Sky Bet app ")

PoisonobjectAddiction Toxicomania………………………………………………………………………………√Sky Bet app □Sky Bet app

Nervous disorder Mental Confusion………………………………………………………………………√Sky Bet app □Sky Bet app

GodScripturesDisease psychosis: Right -typeManic psychosis…………………………………………………………√Sky Bet app □Sky Bet app

delusional typeParanoid psychosis…………………………………………………… □√Sky Bet app □Sky Bet app

Fantasy typeHallucinate psychosis……………………………………………… □√Sky Bet app □Sky Bet app

Height cm

Height cm

Weight kg

Weight kg

Blood pressure Knipa

blood Pressure KPA

Development

Development

Nutrition

Nourishment

Cervical

Next

visionLeftL

Vision RightR

Correct vision LeftL

Correct Vision RightR

Eye

Eyes

color discerning force

Colour Sense

Skin

Skin

lymph nodes

lymph nodes

Ear

Ears

Nose

Nose

tonsil

tonsils

Heart

Heart

Lung

LUNGS

Abdomen

Abdomen

Spine Pillar

spine

4 limbs

Extremities

nervous system

Nervous System

Other see

Other Abnormal Findings

chestDepartmentX Line

CheckCheckknotFruit

(Affiliated Report Elberry)

Chest x-ray

Exam

(Attached

Chest x-ray

Report

ECG

ECG

HuatestRoomCheckCheck

(includingHIVantibodies, syphilis and other serum examination, Attach the original inspection report form)

Laboratory Exam

(Attached Test Report of Aids, Syphilis ETC)

Hepatitis C antibody/anti-HCV：

Alanine base metastases/GPT：(& lt; 29U/L)

Syphilis confirmation test/TPPA：

AIDS virus antibody/anti-HIV：

Sky Bet app diseases with the following quarantine infectious diseases and diseases that endanger public health:

None of the Following Sky Bet app or Disorders Found During the Present Examination

Huo Chaos chlolera sex Disease Venereal Disease

Yellow fever Yellow Fever Tuberculosis lung tuberculosis

Rat Epidemic Plague AIDS AIDS

Ma Wind leprosy mental illness psychosis

Italia see Checking unit stamp

Suggestion Sky Bet app abnormal discovery. Office Stamp

Signature of the doctor Date year month Day

Signature of Physician Date