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FHA ARM EAR FOREIGNER PHYSICAL EXAMINATION FORM gt fta! | O #5 Male th#+H Fa Name Sex | Female Birthday (‡92S#bHIs) EAE a Et Photo Present mailing address (Stamped Official ElfäEEHU[X uy Ae HH mz Stamp) Blood type Nationality Birth (or Area) place WHEABS Mem: ( #1IfllEimiRillS“®”5st“K” ) Have you ever had any of the following diseases? (Each item must be answered “Yes” or “No”} HH Ú#S Typhusfever No oYes li Bacillary dysentery nNo nYes Brucellosis nNo nYes /JVJLRMBTHE Poliomyelitis nNo nYes f#bKHÑA Viral hepatitis ONo oYes — Puerperal streptococcus H M& Diphtheria ONo oYes InSMMX infection nYes nNo nYes 442 21 # Scarletfever No nYes 77 4#8HAHEEX nYes [=] J Relapsing nNo nYes Re 3X fever HEMT Ae Typhoid and paratyphoid fever nNo JN{TMHMEBEHRZ€ Epidemic cerebrospinal meningitis ONo ZORA k©?If&2\RfAÁIAIS^®l9J7ñ1E : (S11 BiHiRIlS“®”5sÈ“£”) Do you have any of the following diseases or disorders endangering the public order and security? (Each item must be answered “Yes” or “No”) I1 Mental TOXỈCOImahia (5.-5 5c.cọ.c n se.s.e se se, nNo nYes kat! tHOL : ƒR5TU confusỉon 2.e.