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: ×× ××, ××××

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