醫院標誌

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1 醫院標誌 Hospital s Logo 健康檢查證明應檢查項目表 ( 乙表 ) ( 醫院名稱地址電話傳真機 ) ITEMS REQUIRED FOR HEALTH CERTIFICATE (Form B) (Hospital s Name, Address, Tel, FAX) 基本資料 ( BASIC DATA) 檢查日期 / / ( 年 ) ( 月 ) ( 日 ) / / (M) (D) (Y) Date of Examination 姓名 : 性別 : 男 Male 女 Female Name Sex 身份證字號 : 護照號碼 : ID No. Passport No. 出生年月日 : / / 國籍 : Date of Birth Nationality 年齡 : 聯絡電話 : Age Phone No. 照片 Photo 實驗室檢查 (LABORATORY EXAMINATIONS) A. HIV 抗體檢查 (Serological Test for HIV Antibody): 陽性 (Positive) 陰性 (Negative) 未確定 (Indeterminate) a. 篩檢 (Screening Test): EIA PA 其他 (Others) b. 確認 (Confirmatory Test): Western Blot 其他 (Others) 兒童 15 歲以下免驗 (Not required for children under 15 years of age) B. 胸部 X 光檢查肺結核 (Chest X-Ray for Tuberculosis): X 光發現 (Findings): 判定 (Results): 合格 (Passed) 疑似肺結核 (TB Suspect) 無法確認診斷 ( Pending) 不合格 (Failed) ( 經臺灣健檢醫院判定為疑似肺結核或無法確認診斷者, 得至指定機構複驗 ; 但所在縣市無指定機構者, 得至鄰近醫院之胸腔科門診複檢 ) (Those who are determined to be TB suspects or have a pending diagnosis by the designated hospital in Taiwan must visit the referred institution for further evaluation.) 孕婦或兒童 12 歲以下免驗 (Not required for pregnant women or children under 12 years of age) C. 腸內寄生蟲 ( 含痢疾阿米巴等原蟲 ) 糞便檢查 ( 採用離心濃縮法檢查 )(Stool examination for parasites includes Entameba histolytica etc.)(centrifugal concentration method): 陽性, 種名 ( Positive, Species ) 陰性 (Negative) 其他可不予治療之腸內寄生蟲 (Other parasites that do not require treatment) 兒童 6 歲以下或來自特定地區者免驗 (Not required for children under 6 years of age or applicants from designated areas as described in Note 6) D. 梅毒血清檢查 (Serological Test for Syphilis): 檢驗 (Tests):a. RPR 或 VDRL b. TPHA/TPPA c. 其它 (Other) 判定 (Results): 合格 (Passed) 不合格 (Failed)

2 兒童 15 歲以下免驗 (Not required for children under 15 years of age) E. 麻疹及德國麻疹之抗體陽性檢驗報告或預防接種證明 (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 未確定 (Equivocal) 德國麻疹抗體 rubella antibody titers 陽性 Positive 陰性 Negative 未確定 (Equivocal) b. 預防接種證明 Vaccination Certificates ( 含接種日期接種院所及疫苗批號 ; 接種日期與出國日期應至少相隔兩週 ) (The Certificate should include the date of vaccination, the name of administering hospital or clinic and the batch no. of vaccine; the date of vaccination should be at least two weeks prior to going abroad) 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) 漢生病檢查 (EXAMINATION FOR HANSEN S DISEASE) 全身皮膚視診結果 (Skin Examination) 正常 Normal 異常 Abnormal: 非漢生病 (not related to Hansen s disease): 漢生病 ( 疑似個案須進一步檢查 )(Hansen s disease suspect needs further exam) a. 病理切片 (Skin Biopsy): b. 皮膚抹片 (Skin Smear): 陽性 ( Finding bacilli in affected skin smears ) 陰性 (Negative) c. 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) 判定 (Results): 合格 (Passed) 不合格 (Failed) 來自特定地區者免驗 (Not required for applicants from designated areas as described in Note 6) 備註 (Note): 一本表供外籍人士無戶籍國民大陸地區人民及香港澳門居民申請在臺灣居留或定居時使用 This form is for residence application. 二兒童 6 歲以下免辦理健康檢查, 但須檢具預防接種證明備查 ( 年滿 1 歲以上者, 至少接種 1 劑麻疹德國麻疹疫苗 ) A child under 6 years old is not necessary to have laboratory examination, but the certificate of vaccination is necessary. Child age one and above should get at least one dose of measles and rubella vaccines. 三懷孕婦女及兒童 12 歲以下免接受胸部 X 光檢查 ; 懷孕婦女於產後仍應補照胸部 X 光 Pregnant women and children under 12 years of age are exempted from chest X-ray examination. Pregnant women should undergo chest X- ray after the child s birth. 四申請免除胸部 X 光檢查之適用對象 : 申請人限來自結核病盛行率低於十萬分之三十的國家, 並檢具由精神科醫師出具申請人在心理上不適合進行胸部 X 光檢查之診斷證明書, 經行政院衛生署疾病管制局審核通過者, 始得免除此項檢測五兒童 15 歲以下免接受 HIV 抗體檢查及梅毒血清檢查 A child under 15 years old is not necessary to have Serological Test for HIV or Syphilis. 六居住於美國加拿大歐洲紐西蘭澳洲日本南韓香港澳門新加坡及以色列等地區或國家之申請者, 得免驗腸內寄生蟲糞便檢查及漢生病檢查 Applicants living in USA, Canada, Europe, New Zealand, Australia, Japan, South Korea, Hong Kong, Macao, Singapore or Israel are not required to undergo a stool examination for parasites or an examination for Hansen s disease. 七漢生病檢查為全身皮膚檢查, 受檢者可穿著內衣內褲, 並由親友或女性醫護人員陪同受檢檢查時逐步分部位受檢, 避免一次脫光全身衣物, 維護受檢者隱私 Hansen s disease examination refers to careful examination of the entire body surface, which should be done with courtesy and respect to the applicant s privacy. During the examination,

3 the applicant is allowed to wear underwear and be accompanied by a friend or female medical personnel. Hospitals or clinics have the responsibilities to protect the privacy of the applicant and the examination should be done step by step. Hence, taking off all clothes at the same time should be avoided. 八根據以上對合格不合格須進一步檢查 Result:According to the above medical report of Mr./Mrs./Ms. 先生 / 女士 / 小姐之檢查結果為, he/she has passed the examination has failed the examination needs further examination. (Chief Medical Technologist) ( Chief Physician ) ( Superintendent ) 日期 (Date): / / 本證明三個月內有效 (Valid for Three Months)

4 附錄 : 健康檢查證明不合格之認定原則檢查項目不合格之認定原則人類免疫缺乏病一人類免疫缺乏病毒抗體檢驗經初步測試, 連續二次呈陽性反應者, 應以西方墨點法 (WB) 作確認毒抗體檢查試驗二連續二次 ( 採血時間需間隔三個月 ) 西方墨點法結果皆為未確定者, 視為合格胸部 X 光檢查一活動性肺結核 ( 包括結核性肋膜炎 ) 視為不合格二非活動性肺結核視為合格, 包括下列診斷情形 : 纖維化 ( 鈣化 ) 肺結核纖維化 ( 鈣化 ) 病灶及肋膜增厚腸內寄生蟲糞便檢查一經顯微鏡檢查結果為腸道蠕蟲蟲卵或其他原蟲類如 : 痢疾阿米巴原蟲 ( Entamoeba histolytica) 鞭毛原蟲類, 纖毛原蟲類及孢子蟲類者為不合格二經顯微鏡檢查結果為人芽囊原蟲及阿米巴原蟲類, 如 : 哈氏阿米巴 (Entamoeba hartmanni) 大腸阿米巴 (Entamoeba coli) 微小阿米巴 (Endolimax nana) 嗜碘阿米巴 (Iodamoeba butschlii) 雙核阿米巴 (Dientamoeba fragilis) 唇形鞭毛蟲 (Chilomastix mesnili) 等, 可不予治療, 視為合格三妊娠孕婦如為寄生蟲檢查陽性者, 視為合格 ; 請於分娩後, 進行治療梅毒血清檢查一以 RPR 或 VDRL 其中一種加上 TPHA(TPPA) 之檢驗, 如檢驗結果有下列情形任一者, 為不合格 : ( 一 ) 活性梅毒 : 同時符合條件 ( 一 ) 及 ( 二 ) 或僅符合條件( 三 ) 者 ( 二 ) 非活性梅毒 : 僅符合條件 ( 二 ) 者二條件 : ( 一 ) 臨床症狀出現硬下疳或全身性梅毒紅疹等臨床症狀 ( 二 ) 未曾接受梅毒治療或病史不清楚者,RPR(+) 或 VDRL(+), 且 TPHA (TPPA)=1:320 以上 ( 含 320) ( 三 ) 曾經接受梅毒治療者,VDRL 價數上升四倍三梅毒血清檢查陽性者, 檢具治療證明, 視為合格麻疹德國麻疹麻疹德國麻疹抗體檢查結果為陰性 ( 或未確定者 ), 且未檢具於抗體檢查後之麻疹德國麻疹預防接種證明者, 視為不合格但經醫師評估有麻疹德國麻疹疫苗接種禁忌者, 視為合格 Appendix: Principles in determining the health status failed Test Item Serological Test for HIV Antibody Chest X-ray Stool Examination for Parasites Serological Test for Syphilis Measles, Rubella Principles on the determination of failed items 1. If the preliminary testing of the serological test for HIV antibody is positive for two consecutive times, confirmation testing by WB is required. 2. When findings of two consecutive WB testing (blood specimens collected at an interval of three months) are indeterminate, this item is considered qualified. 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. 1. By microscope examination, cases are determined unqualified if intestinal helminthes eggs or other protozoa such as Entamoeba histolytica, flagellates, ciliates and sporozoans are detected. 2. Blastocystis hominis and Amoeba protozoa such as Entamoeba hartmanni, Entaboeba coli, Endolimax nana, Iodamoeba butschlii, Dientamoeba fragilis, Chilomastix mesnili found through microscope examination are considered qualified and no treatment is required. 3. Pregnant women who have positive result for parasites examination are considered qualified and please have medical treatment after the child s birth. 1. After testing by either RPR or VDRL together with TPHA(TPPA), if cases meet one of the following situations are considered failing the examination. (1)Active syphilis: must fit the criterion (1) + (2) or only the criterion (3). (2)Inactive syphilis: only fit the criterion (2). 2. 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 fourfold or greater increase from the last nontreponemal test titer. 3. Those that have failed the serological test for syphilis but have submitted a medical treatment certificate are considered passing the examination. The item is considered unqualified if measles or rubella antibody is negative (or equivocal) and no measles, rubella vaccination certificate issued after the antibody test is provided. Those who having contraindications, not suitable for vaccinations are considered qualified. 03/06/2012

醫院標誌

醫院標誌醫院標誌 Hospital s Logo 健康檢查證明應檢查項目表 ( 乙表 ) ( 醫院名稱地址電話傳真機 ) ITEMS REQUIRED FOR HEALTH CERTIFICATE (Form B) (Hospital s Name, Address, Tel, FAX) 基本資料 ( BASIC DATA) 檢查日期 / / (