| MEDICAL EXAMINATION RECORD BY AUXILIARY CLINIC OF ×××× HEALTH CONTROL CADRES INSTITUTE | ||||||||
| Date: ××. ××, ×××× |
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| Name | ×××××× | Sex | ×× | Age | ×× | Native | ××,×× | (Photo) |
| Occupation | ×××× | Preventive Injection Status |
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| 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 |
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| Lymph | Spine | (See skin sector, if necessary) | |||||
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| Anus | Normal | Hernia | None | Other disease | / | ||
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| Genitals | |||||||
| Ophthalmolopy | Eyesight: Left | ×× | Color distinguish | Normal | Trachoma | / | Other disease / | ×××× |
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| 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.) |
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| Special examination | X-ray | Heart normal | Blood analysis |
| Others |
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| Conclusion | Normal | Signature of doctor making conclusion | ×××× | Seal of clinic | Auxiliary clinic of Sichuan Health Control Cadres Institute | Date: ×× ××, ×××× | ||