大陆配偶团聚健康检查证明

大陆配偶团聚健康检查证明 检查日期 ____/____/____ 团聚健康检查证明 附 (月) (日) (年) (医院名称、地址、电话、传真机) (健检医院可另行开立具有医院标志之健康证明) 基 本 资 料 ( BASIC DATA) 姓 名 性別 , , ?男Male ?女Female Name ––––––––––––––––––––– Sex 照片 身分證字號 , ID No. ________________________ 護照號碼 出生年月日 , , _____ / _____ / _____ Passport No. ________________ Date of Birth Photo 实 验 室 检 查(LABORATORY EXAMINATIONS) A. HIV抗體檢查,Serological Test for HIV Antibody,,?陽性,Positive, ?陰性,Negative, ?未確定,Indeterminate, ,.篩檢,Screening Test,, ?EIA ?Serodia ?其他,Others,______________ ,.確認,Confirmatory Test,,?Western Blot ?其他,Others,______________ B.胸部X光檢查肺結核,Chest ,-Ray for Tuberculosis,,,妊娠孕婦可免接受「胸部,光檢查」, ?正常,Normal, ?異常 ( Abnormal ) __________________※限大片攝影,Standard Film Only, C.腸內寄生蟲,含痢疾阿米巴等原蟲,糞便檢查,Stool examination for parasites includes Entameba histolytica etc.,,?陽性,種名( Positive, Species ) ______________________ ?陰性,Negative, D. 梅毒血清檢查,Serological Test for Syphilis,,?陽性,Positive, ?陰性,Negative, ,.?RPR ,.?VDRL ,.?TPHA/TPPA ,.?其它,Other, E. 申請者應檢具麻疹、德國麻疹(風疹)抗體陽性檢驗報告或提供麻疹、德國麻疹預防接種證明,Applicant should provide proof of positive measles and rubella antibody titers or measles and rubella vaccination certificates,, a. ?抗體檢查,Antibody test,麻疹抗體measles antibody titers ?陽性Positive ?陰性 Negative 德國麻疹抗體rubella antibody titers ?陽性Positive ?陰性 Negative b. ?預防接種證明 Vaccination Certificates ?麻疹預防接種證明Vaccination Certificates of Measles ?德國麻疹預防接種證明Vaccination Certificates of Rubella c. ?經醫師評估,有接種禁忌者,暫不適宜接種。(Having contraindications, not suitable for vaccination) 汉 生 病 检 查(CHECK-UP FOR Hansen’s disease) 漢生病(麻風病)視診結果(Skin Check-up) ?正常Normal ?異常Abnormal (※視診異常者,須進一步採檢 確認) (※If abnormal skin lesion is found, further skin biopsy or skin smear is required) ,.病理切片(Skin Biopsy),?陽性,多菌、少菌性【Positive - MB,PB】,診斷依據,兩者之一即為陽性 【Diagnostic if either of them positive】, ?陰性,Negative, ,.皮膚抹片(Skin Smear),?陽性 ( Finding bacilli in affected skin smears ) ?陰性,Negative, ※皮膚病灶合併感覺喪失或神經腫大( Skin lesions combined with sensory loss or enlargement of peripheral nerves ) ?有,Yes, ?無,No, 备注: 一、本表供大陆地区人民首次申请来台团聚时使用。This form is for use in applying for reunion in Taiwan. 二、妊娠孕妇可免接受「胸部,光检查」。A pregnant woman is not necessary to have chest X-ray examination. 三、梅毒血清检查阳性者，检具治疗证明，视为合格。Those who have positive results for serological test for syphilis should submit medical treatment certificate. 四、健康检查证明不合格之认定原则详如附录。Appendix is principles in determining the health status failed. 五、根据以上对 先生/女士/小姐之检查结果为 ? 合格 ? 不合格。 Conclusion: This is to certify that, based on the above medical report, Mr/Mrs/Ms _____________________, He/She ? passes ? fails the checkup. 负负责医师签章(Chief Physician): _______________ 医 院 负 责 人 签 章(Superintendent): _____________ 日期(Date): / / ※本证明三个月内有效(Vaild for Three Months)01/01/2009 附录:健康检查证明不合格之认定原则 检验项目 不合格之认定原则 人类免疫缺乏病一、人类免疫缺乏病毒抗体检验经初步测试，连续二次呈阳性反应者，应以西方墨点法(WB)作确 毒抗体检查 认试验。 二、连续二次(采血时间需间隔三个月)西方墨点法结果皆为未确定者，视为合格。 胸部,光检查 一、活动性肺结核(包括结核性肋膜炎)视为「不合格」。 二、非活动性肺结核视为「合格」，包括下列诊断情形:纤维化(钙化)肺结核、纤维化(钙化)病灶及 肋膜增厚。 肠内寄生虫粪便一、 经显微镜检查结果为肠道蠕虫虫卵或其他原虫类如:痢疾阿米巴原虫(Entamoeba histolytica)、 检查 鞭毛原虫类，纤毛原虫类及孢子虫类者为不合格。 二、经显微镜检查结果为人芽囊原虫及阿米巴原虫类，如:哈氏阿米巴(Entamoeba hartmanni)、 大肠阿米巴(Entamoeba coli)、微小阿米巴(Endolimax nana)、嗜碘阿米巴(Iodamoeba butschlii)、 双核阿米巴(Dientamoeba fragilis)等，可不予治疗，视为「合格」。 梅毒 一、以RPR或VDRL其中一种加上TPHA(TPPA)之检验，如检验结果有下列情形任一者，为「不 合格」: (一)活性梅毒:同时符合通报条件(一)及(二)、或仅符合通报条件(三)者。 (二)非活性梅毒:仅符合通报条件(二)者。 二、通报条件: (一)临床症状出现硬下疳或全身性梅毒红疹等临床症状。 (二)未曾接受梅毒治疗或病史不清楚者，RPR(+)或VDRL(+)，且TPHA (TPPA)=1:320以上(含 320)。 (三)曾经接受梅毒治疗者，VDRL价数上升四倍。 麻疹、德国麻疹 麻疹、德国麻疹(风疹)抗体阴性且未检具麻疹、德国麻疹预防接种证明者为不合格。但经医师评估 (风疹) 有麻疹、德国麻疹疫苗接种禁忌者，视为合格。 Appendix: Principles in determining the health status failed Test Item Principles on the determination of failed items Serological Test 1. If the preliminary testing of the serological test for HIV antibody is positive for two consecutive times, for HIV confirmation testing by WB is required. Antibody 2. When findings of two consecutive WB testing (blood specimens collected at an interval of three months) are indeterminate, this item is considered qualified. Chest X-ray 1. Active pulmonary tuberculosis (including tuberculous pleurisy) is unqualified. 2. Non-active pulmonary tuberculosis including calcified pulmonary tuberculosis, calcified foci and enlargement of pleura, is considered qualified. Stool 1. By microscope examination, cases are determined unqualified if intestinal helminthes eggs or other Examination for protozoa such as Entamoeba histolytica, flagellates, ciliates and sporozoans are detected. Parasites 2. Blastocystis hominis and Amoeba protozoa such as Entamoeba hartmanni, Entaboeba coli, Endolimax nana, Iodamoeba butschlii, Dientamoeba fragilis found through microscope examination are considered qualified and no treatment is required. Serological Test 1. After testing by either RPR or VDRL together with TPHA(TPPA), if cases meet one of the following for Syphilis situations are considered failing the examination. (1)Active syphilis: must fit reportable criterion (1) + (2) or only reportable criterion (3). (2)Inactive syphilis: only fit reportable criterion (2). 2. Reportable criterion: (1)Clinical symptoms with genital ulcers (chancres) or syphilis rash all over the body. (2)No past diagnosis of syphilis, a reactive nontreponemal test (i.e., VDRL or RPR), and TPHA(TPPA),1:320?(including 1:320) (3)A past history of syphilis therapy and a current nontreponemal test titer demonstrating four fold or greater increase from the last nontreponemal test titer. Measles, The item is considered unqualified if measles or rubella antibody is negative and no measles, rubella Rubella vaccination certificate is provided. Those who having contraindications, not suitable for vaccinations are considered qualified.