个人健康告知书-英文2023.04.21.docx

个人健康告知书 Personal Health Declaration with Reference in English 姓名 性别 Name Gender 出生日期 护照号码 Date of birth Passport No. 根据学校聘用工作人员体检标准要求，请回答如下问题： Please answer the following questions in accordance with medical examination criteria for staff employed by the university: 1.您是否患有风湿性心脏病、心肌病、冠心病、先天性心 是 否 脏病等器质性心脏病。 Yes No 是 否 Yes No 3.您是否患有血液系统疾病。 是 否 3. Whether you have blood system disease. Yes No 4.您是否患有结核病。 是 否 4. Whether you have tuberculosis. Yes No 5.您是否患有慢性支气管炎伴阻塞性肺气肿、支气管扩 是 否 张、支气管哮喘。 Yes No 1. Whether you have rheumatic heart disease, cardiomyopathy, coronary heart disease, congenital heart disease and other organic heart disease. 2.您是否收缩压大于 140mmHg；舒张压大于 90mmHg。 2. Whether your systolic blood pressure is greater than 140mmHg; diastolic blood pressure is greater than 90mmHg. 5. Whether you have chronic bronchitis with obstructive emphysema, bronchiectasis and bronchial asthma. 6.您是否患有慢性胰腺炎、溃疡性结肠炎、克罗恩病等严 是 否 重慢性消化系统疾病。 Yes No 7.您是否患有各种急慢性肝炎及肝硬化。 是 否 7. Whether you have kinds of acute or chronic hepatitis and Yes No 8.您是否患有恶性肿瘤。 是 否 8. Whether you have malignant tumors. Yes No 9.您是否患有肾炎、慢性肾盂肾炎、多囊肾、肾功能不 是 否 全。 Yes No 10.您是否患有糖尿病、尿崩症、肢端肥大症等内分泌系 是 否 统疾病。 Yes No 11.您是否有癫痫病史、精神病史、癔病史、夜游症、严 是 否 重的神经官能症（经常头痛头晕、失眠、记忆力明显下降 Yes No 6. Whether you have chronic pancreatitis, ulcerative colitis, Crohn’s disease and other serious chronic digestive diseases. cirrhosis. 9. Whether you have nephritis, chronic pyelonephritis, polycystic kidney, and renal insufficiency. 10. Whether you have diabetes, diabetes insipidus, acromegaly and other endocrine system disease. 等），是否是精神活性物质滥用和依赖者。 11. Whether you have a history of epilepsy, psychosis and hysteria, noctambulism and serious neurosis (often headache, dizziness, insomnia, memory decreased, etc.), and whether you are a psychoactive substance abuser or dependent. 12.您是否患有红斑狼疮、皮肌炎和/或多发性肌炎、硬皮 是 否 病、结节性多动脉炎、类风湿性关节炎等各种弥漫性结缔 Yes No 13.您是否患有晚期血吸虫病，晚期血丝虫病兼有橡皮肿 是 否 或有乳糜尿。 Yes No 14.您是否患有颅骨缺损、颅内异物存留、颅脑畸形、脑 是 否 外伤后综合征。 Yes No 15.您是否患有严重的慢性骨髓炎。 是 否 15. Whether you have serious chronic osteomyelitis. Yes No 16.您是否患有三度单纯性甲状腺肿。 是 否 16. Whether you have three degree simple goiter. Yes No 17.您是否患有有梗阻的胆结石或泌尿系结石。 是 否 17. Whether you have obstructive gallstones or urinary stones. Yes No 18.您是否患有淋病、梅毒、软下疳、性病性淋巴肉芽 是 否 肿、尖锐湿疣、生殖器疱疹，艾滋病。 Yes No 组织疾病，大动脉炎。 12. Whether you have lupus erythematosus, dermatomyositis and/or polymyositis, scleroderma, polyarteritis nodosa, rheumatoid arthritis and other connective tissue diseases, and arteritis. 13. Whether you have advanced schistosomiasis and advanced filariasis with elephantiasis or chyluria. 14. Whether you have skull defects, intracranial foreign body retention, brain malformation and brain post-traumatic syndrome. 18. Whether you have gonorrhea, syphilis, chancroid, lymphogranuloma, condyloma acuminatum, genital herpes and HIV/AIDS. 19.您是否患有霍乱、黄热病、开放性肺结核、鼠疫、麻 是 否 风。 Yes No 20.您是否是有明显视功能损害眼病者。 是 否 20. Whether you are an eye patient with obvious visual Yes No 21.您是否是双耳均有听力障碍，在使用人工听觉装置情 是 否 况下，双耳在 3 米以内耳语仍听不见者。 Yes No 22.您是否曾患有斑疹伤寒、细菌性痢疾、小儿麻痹症、 是 否 布氏杆菌病、白喉、病毒性肝炎、猩红热、产褥期链球 Yes No 23.您在过去 1 年内是否发现健康检查异常（物理检查、 是 否 血液检查、尿液检查、体液检查、心电图、超声波检查、 Yes No 19. Whether you have cholera, yellow fever, open tuberculosis, pestis and leprosy. impairment. 21. Whether your both ears have hearing impairment. Both ears still can not hear, wearing artificial hearing devices, within 3 meters whisper. 菌、回归热、伤寒和副伤寒、流行性脑脊髓膜炎、感染。 22. Whether you have ever had typhus, bacillary dysentery, poliomyelitis, brucellosis, diphtheria, viral hepatitis, scarlet fever, puerperal streptococcus, relapsing fever, typhoid fever and paratyphoid fever, epidemic cerebrospinal meningitis and infection. 影像检查、内窥镜检查、病理检查、介入检查），过去 2 年是否住院或被要求进一步检查、手术或治疗。 23. Whether you have found any abnormality in health check (physical examination, blood examination, urine examination, body fluid examination, electrocardiogram, ultrasound examination, imaging examination, endoscopy, pathological examination, interventional examination) in the past 1 year, and whether you have been hospitalized or asked for further examination, surgery or treatment in the past 2 years. 对上述情况的进一步说明： Further explanation of the above: 本人承诺： 1.本人确认上述陈述是完整、属实的。 2.本人知道任何健康上的变化应在签订合同前通知学校。 3.本人知道，若在入职体检（含入境前及入境后体检）中发现本人符合以上 任一情况或患有影响正常履行工作职责的其他严重疾病，将导致本人无法履 行合同，合同失效或即刻解除。由此带来的后果，由本人自行承担。 My declaration: 1. I declare that the statements made above are complete and true. 2. I understand that any change in health should be notified to the university prior to signing the contract. 3. I know that if I meet any of the above situations or suffer from other serious diseases that affect the normal performance of my duties in the medical examination (including medical examinations in my country and in China), I will be unable to perform the contract, and the contract will be invalid or immediately terminated. The consequences therefrom shall be undertaken by myself. 本人签字： 签字日期： Signature: Date: