MEDICAL  EXAMINATION  RECORD  BY  AUXILIARY  CLINIC  OF ××××  HEALTH  CONTROL  CADRES  INSTITUTE

Date: ××. ××, ××××

Clinic No.

Name

××××××

Sex

××

Age

××

Native

××,××

(Photo)

Occupation

××××

Preventive Injection Status

Do you have any disease, what treatment received and how about it now?

None

Common Examination

Height

×× cm

Weight

×× kg

Breath

Others

Signature of doctor

Internal

Heart

(-)

Lung

(-)

Liver

Not involved

××

Spleen

Blood pressure

××/× kpa

Nutritive condition

Good

Nerve

(-)

Others

/

Surgery

Hypothyroid

Normal

Limb

Normal

Skin

Normal

Lymph

Spine

(See skin sector, if necessary)

Anus

Normal

Hernia

None

Other disease

/

Genitals

Ophthalmolopy

Eyesight: Left

×× 

Color distinguish

Normal

Trachoma

/

Other disease /

××××

              Right

×× 

E.N.T

Listening: left

××/××

Ear disease: None

Nose disease: None

Thyoat

Normal

Other disease /

××××

           Right

Stomatorlogy

Dental caries

None

Other disease

Normal

××××

Gynecology

(If necessary, it may be checked free of charge, but for other special examination, ie. X-ray, blood analysis, leucorrhea analysis, etc., it will be charged additionally.)

Special examination

X-ray

Heart normal

Blood analysis

Others

Conclusion

Normal

Signature of doctor making conclusion

××××

Seal of clinic

Auxiliary clinic of Sichuan Health Control Cadres Institute

Date: ×× ××, ××××