醫院標誌 Hospital s Logo 居留或定居健康檢查項目表 Health Certificate for Residence Application ( 醫院名稱 地址 電話 傳真 ) (Hospital s Name, Address, Tel, Fax) 檢查日期 / Date of Examination YYYY / MM / DD 姓名 Name 身份證字號 ID No. 出生年月日 YYYY / MM / DD Date of Birth 年齡 Age 基本資料 / Basic Data 性別 男 / M 女 / F Sex 護照號碼 Passport No. 國籍 Nationality 聯絡電話 Phone No. 照片 / Photo 實驗室檢查 / Laboratory Examinations A. 胸部 X 光肺結核檢查 / Chest X-ray for Tuberculosis X 光發現 / Findings 判定 / Result 合格 / Passed 疑似肺結核 / TB suspect 無法確認診斷 / Pending 不合格 / Failed 孕婦或 12 歲以下兒童免驗 / Not required for pregnant women or children under 12 years of age B. 腸內寄生蟲糞便檢查 / Stool Examination for ParasitesNot required for applicants coming from France and others countries/areas listed on Appendix 3 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 來自附錄三之國家 / 地區者免驗 / Not required for applicants from countries/areas listed in Appendix 3 C. 梅毒血清檢查 / Serological Tests for Syphilis 檢驗 / Tests a. RPR VDRL 陽性 / Positive, 效價 / Titers b. TPHA TPPA FTA-abs TPLA EIA CIA 陽性 / Positive, 效價 / Titers c. other 陽性 / Positive, 效價 / Titers 判定 / Result 合格 / Passed 不合格 / Failed 15 歲以下兒童免驗 / Not required for children under 15 years of age D. 麻疹及德國麻疹之抗體陽性檢查報告或預防接種證明 / Proof of Positive Measles and Rubella Antibody or Measles and Rubella Vaccination Certificates a. 抗體檢查 / Antibody Tests 麻疹抗體 / Measles Antibody 陽性 / Positive 陰性 / Negative 未確定 / Equivocal 德國麻疹抗體 / Rubella Antibody 陽性 / Positive 陰性 / Negative 未確定 / Equivocal b. 預防接種證明 / Vaccination Certificates ( 證明應包含接種日期 接種院所及疫苗批號 ; 接種日期與出國日期應至少間隔兩週 / 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 traveling overseas.) 麻疹預防接種證明 / Measles Vaccination Certificate 德國麻疹預防接種證明 / Rubella Vaccination Certificate c. 有接種禁忌, 暫不適宜預防接種 / Having contraindications, not suitable for vaccination
漢生病檢查 / Examinations for Hansen s Disease Not required for applicants coming from France and others countries/areas listed on Appendix 4 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 疑似漢生病須進一步檢查 / Hansen s disease suspect who needs further examinations a. 病理切片 / Skin Biopsy b. 皮膚抹片 / Skin Smear 陽性 / Positive 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 / Result 合格 / Passed 須進一步檢查 / Needs further examinations 不合格 / Failed 來自附錄四之國家 / 地區者免驗 / Not required for applicants from countries/areas listed in Appendix 4 健康檢查總結果 / The final result of health examination 合格 / Passed 須進一步檢查 / Need further examinations 不合格 / Failed 負責醫檢師簽章 / Signature of Chief Medical Technologist 負責醫師簽章 / Signature of Chief Physician 醫院負責人簽章 / Signature of Superintendent 日期 / DateYYYY / MM / DD 備註 / Note 本證明三個月內有效 / The certificate is valid for three months.
附錄一愛滋篩檢與治療費用通知書 ( 請健檢醫院將此通知書併同健康檢查證明發給受檢者 ) 一 中華民國政府已修改法規, 取消非本國籍人類免疫缺乏病毒 (HIV) 感染者之入境 停留及居留限制, 也取消此項健康檢查項目 二 由於非本國籍人士在中華民國治療 HIV 感染之費用, 中華民國政府不提供補助, 每年治療費用約為新臺幣三十萬元 ( 約美金一萬元 ), 建議非本國籍人士先於母國接受 HIV 篩檢, 了解自身健康狀況 ; 如為 HIV 感染者, 建議留在母國接受治療 欲來中華民國工作者, 請先行購買醫療保險, 以免造成個人財務負擔 三 外籍人士進入中華民國後, 可自行至醫院進行 HIV 篩檢, 了解自身感染狀況, 傳染病諮詢電話為 0800-001922 Appendix 1 Notice for HIV Screening and Treatment Costs (Health examination hospitals shall issue this notice and health certificate to the examinee) 1. The Government of Republic of China (Taiwan) has revised its laws to lift restrictions on entry, stay and residence of non-roc nationals infected with human immunodeficiency virus (HIV) in addition to removing this item from health examination. 2. The Government of Republic of China (Taiwan) does not offer subsidies to non-roc nationals infected with HIV infection for treatment in Taiwan. The annual treatment costs for HIV is NTD$300,000 (approximately USD$10,000). It is strongly advised that non-roc nationals to undergo HIV screening in their homeland prior to visiting Taiwan in order to understand their own health conditions. Persons infected with HIV are strongly advised to stay in their homeland for treatment. Persons intending to work in Taiwan are advised to purchase medical health insurance in advance to avoid financial burdens. 3. Upon entry into the Republic of China (Taiwan), foreigners may undergo HIV screening at a hospital to determine their infection status. The consultation hotline for infectious diseases is 0800-001922. 附錄二辦理居留或定居健康檢查補充說明事項 Appendix 2 Additional instructions of health examination for residence application 一 6 歲以下兒童免辦理健康檢查, 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 ) Children under 6 years of age are exempt from health examination, but the certificate of vaccination is necessary. (Child age one and above should get at least one dose of measles and rubella vaccines). 二 懷孕婦女及 12 歲以下兒童免驗胸部 X 光檢查 ; 懷孕婦女於產後應補辦理胸部 X 光檢查 Pregnant women and children under 12 years of age are exempt from chest X-ray examination; Pregnant women should undergo chest X-ray examination after the child s birth. 三 得申請免驗胸部 X 光檢查之資格 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, 經衛生福利部疾病管制署審核通過者, 始得免除此項檢查 Qualifications for applying exemption from chest X-ray examination People who are from countries with a tuberculosis prevalence rate of under 30/100,000 and who have received the physical examination certificate that deemed the individual as being unsuitable to undergo chest X-ray examination, which is verified by CDC, are exempt from the examination. 四 腸道寄生蟲糞便檢查採離心濃縮法 Stool examination for parasites should be done with centrifugal concentration. 五 15 歲以下兒童免驗梅毒血清檢查 Children under 15 years of age are exempt from serological test for syphilis. 六 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, the applicant is allowed to wear underwear and be accompanied by a friend or female medical personnel. Hospitals or clinics have the responsibility 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.
附錄三免驗腸內寄生蟲糞便檢查之國家 / 地區表 Appendix 3 List of countries/areas not required to undergo stool examination for parasites 西太平洋區 Western Pacific Region 澳洲 Australia 汶萊 Brunei Darussalam 澳門 Macao 紐西蘭 New Zealand 香港 Hong Kong 日本 Japan 韓國 Republic of Korea 新加坡 Singapore 臺灣之無戶籍國民 nationals without registered permanent residence in Taiwan 東地中海區 Eastern Mediterranean Region 巴林 Bahrain 科威特 Kuwait 卡達 Qatar 沙烏地阿拉伯 Saudi Arabia 阿拉伯聯合大公國 United Arab Emirates 美洲區 Region of the Americas 阿根廷 Argentina 加拿大 Canada 智利 Chile 美國 United States of America 歐洲區 European Region 阿爾巴尼亞 Albania 安道爾 Andorra 拉脫維雅 Latvia 立陶宛 Lithuania 亞美尼亞 Armenia 奧地利 Austria 盧森堡 Luxembourg 馬爾他 Malta 白俄羅斯 Belarus 比利時 Belgium 摩納哥 Monaco 蒙特內哥羅 Montenegro 英國 United Kingdom 保加利亞 Bulgaria 荷蘭 Netherlands 挪威 Norway 克羅埃西亞 Croatia 賽普勒斯 Cyprus 波蘭 Poland 葡萄牙 Portugal 捷克 Czech Republic 丹麥 Denmark 摩爾多瓦 Republic of Moldova 羅馬尼亞 Romania 愛沙尼亞 Estonia 芬蘭 Finland 俄羅斯 Russian Federation 聖馬利諾 San Marino 法國 France 喬治亞 Georgia 塞爾維亞 Serbia 斯洛伐克 Slovakia 德國 Germany 希臘 Greece 斯洛維尼亞 Slovenia 西班牙 Spain 匈牙利 Hungary 冰島 Iceland 瑞典 Sweden 瑞士 Switzerland 愛爾蘭 Ireland 以色列 Israel 馬其頓 The former Yugoslav Republic of Macedonia 波士尼亞與赫塞哥雅納 Bosnia and Herzegovina 義大利 Italy 哈薩克 Kazakhstan 土庫曼 Turkmenistan 烏克蘭 Ukraine 土耳其 Turkey 附錄四免驗漢生病檢查之國家 / 地區表 Appendix 4 List of countries/areas not required to undergo examination for Hansen s disease 西太平洋區 Western Pacific Region 澳洲 Australia 汶萊 Brunei Darussalam 澳門 Macao 紐西蘭 New Zealand 香港 Hong Kong 日本 Japan 韓國 Republic of Korea 新加坡 Singapore 臺灣之無戶籍國民 nationals without registered permanent residence in Taiwan 美洲區 Region of the Americas 加拿大 Canada 智利 Chile 美國 United States of America 歐洲區 European Region 阿爾巴尼亞 Albania 安道爾 Andorra 拉脫維雅 Latvia 立陶宛 Lithuania 亞美尼亞 Armenia 奧地利 Austria 盧森堡 Luxembourg 馬爾他 Malta 白俄羅斯 Belarus 比利時 Belgium 摩納哥 Monaco 蒙特內哥羅 Montenegro 英國 United Kingdom 保加利亞 Bulgaria 荷蘭 Netherlands 挪威 Norway 克羅埃西亞 Croatia 賽普勒斯 Cyprus 波蘭 Poland 葡萄牙 Portugal 捷克 Czech Republic 丹麥 Denmark 摩爾多瓦 Republic of Moldova 羅馬尼亞 Romania 愛沙尼亞 Estonia 芬蘭 Finland 俄羅斯 Russian Federation 聖馬利諾 San Marino 法國 France 喬治亞 Georgia 塞爾維亞 Serbia 斯洛伐克 Slovakia 德國 Germany 希臘 Greece 斯洛維尼亞 Slovenia 西班牙 Spain 匈牙利 Hungary 冰島 Iceland 瑞典 Sweden 瑞士 Switzerland 愛爾蘭 Ireland 以色列 Israel 馬其頓 The former Yugoslav Republic of Macedonia 波士尼亞與赫塞哥雅納 Bosnia and Herzegovina 義大利 Italy 哈薩克 Kazakhstan 土庫曼 Turkmenistan 土耳其 Turkey 烏克蘭 Ukraine
附錄五 健康檢查不合格之認定及處理原則 檢查項目胸部 X 光肺結核檢查 腸內寄生蟲糞便檢查 梅毒血清檢查 麻疹及德國麻疹抗體檢查 漢生病檢查 不合格之認定及處理原則一 活動性肺結核或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 三 經診斷為 疑似肺結核 或 無法確認診斷 者, 請攜帶體檢報告 胸部 X 光片至指定機構再檢查 ; 所在縣市無指定機構者, 得至鄰近醫院之胸腔科門診再檢查 四 不合格者得留臺治療後重新體檢, 但時間依其停留簽證或入出境許可證之效期為限 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 不合格者得接受治療, 檢具複檢陰性證明者, 視為合格 四 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 一 具下列任一條件, 視為不合格 ( 一 ) 未曾接受梅毒治療或病史不清楚者, 其血清非特異性梅毒螺旋體試驗及特異性梅毒螺旋體試驗陽性 ( 二 ) 曾經接受梅毒治療者, 其血清非特異性梅毒螺旋體試驗效價 4 倍上升 二 血清非特異性梅毒螺旋體試驗及特異性梅毒螺旋體試驗 ( 一 ) 非特異性試驗 快速血漿反應素試驗 (RPR) 或性病研究實驗室試驗 (VDRL) ( 二 ) 特異性試驗 梅毒螺旋體血液凝集試驗 (TPHA) 梅毒螺旋體粒子凝集試驗(TPPA) 梅毒抗體間接螢光染色法 (FTA-abs) 梅毒螺旋體乳膠凝集試驗 (TPLA) 梅毒螺旋體酵素免疫分析法(EIA) 或梅毒螺旋體化學冷光免疫分析法 (CIA) 三 梅毒血清檢查如使用中央衛生主管機關所增列之檢驗方法, 得於其他下增列 四 不合格者得接受治療, 檢具治療證明者, 視為合格 麻疹或德國麻疹抗體檢查報告為陰性或未確定者, 且未檢具麻疹及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及德國麻疹疫苗接種禁忌者, 視為合格 一 經診斷為 須進一步檢查 者, 請至指定機構進一步檢查 ; 所在縣市無指定機構者, 得至鄰近醫院之皮膚科門診 二 不合格者得留臺治療後重新體檢, 但時間依其停留簽證或入出境許可證之效期為限 註 胸部 X 光肺結核檢查或漢生病檢查之再檢查指定機構名單請洽衛生福利部疾病管制署 (http//www.cdc.gov.tw)/ 國際旅遊與健康 / 外國人健檢 / 健檢指定醫院 / 胸部 X 光檢查確認機構名單 或 漢生病個案確診及治療指定機構 Appendix 5 Principles in determining the health examination failed and further procedures Test Chest X-ray for Tuberculosis Stool Examination for Parasites Serological Test for Syphilis Measles and Rubella Antibody test Examination Hansen s Disease for Principles in determining the health examination failed and further procedures 1. Active pulmonary tuberculosis or tuberculous pleurisy is failed. 2. Non-active pulmonary tuberculosis including calcified pulmonary tuberculosis, calcified foci and enlargement of pleura, is considered passed. 3. Those who are determined to be TB suspect or whose results are diagnosed pending diagnosis by the designated hospital in Taiwan must take the report and X-ray films to the referred institution for re-examination; those living in cities/counties without a referred institution, please visit the department of chest medicine at a nearby hospital. 4. People with failed results are allowed to stay for re-examination after receiving treatment, but the duration of stay depends on his/her vistor visa or entry/exit permit. 1. By microscope examination, cases are determined failed 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 passed and no treatment is required. 3. People with failed results can accept treatment, and people with negative re-examination results are considered passed. 4. Pregnant women who have positive result for parasites examination are considered passed and please have medical treatment after the child s birth. 1. Meeting one of the following criterion are considered failed (1) Without past history of syphilis therapy or with unknown history, the non-treponemal test and the treponemal test are positive. (2) With past history of syphilis therapy, the non-treponemal test titers are 4-fold rising. 2. Serological non-treponemal tests and treponemal tests (1) Non-treponemal testsrpr or VDRL. (2) Treponemal teststpha, TPPA, TPLA, EIA, CIA, and FTA-abs. 3. Those who had failed serological test for syphilis but have accepted treatment are considered passed It is considered failed if measles or rubella antibody is negative (or equivocal) and no measles and rubella vaccination certificate issued. Those who have contraindications, not suitable for vaccinations, are considered passed. 1. Those who are determined to need further examinations by the designated hospital in Taiwan must go to the referred institution for further examinations; those living in cities/counties without a referred institution can visit the department of dermatology at a nearby hospital. 2. People with failed result are allowed to stay for re-examination after receiving treatment, but the duration of stay depends on his/her vistor visa or entry/exit permit.