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） 檢查日期 ____/____/____ (年) (月) (日)____/____/____
(Ｍ) (Ｄ) (Ｙ)
Date of Examination
ITEMSREQUIREDFORHEALTHCERTIFICATE （Form B） （Hospital’s Name, Addre, Tel, FAX）
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 neceary to have laboratory examination, but the certificate of vaccination is neceary.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 neceary 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, 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/女士/小姐之檢查結果為
□合格□不合格□須進一步檢查
Result：
□has paed the examination□has failed the examination□needs further examination.責負醫檢師簽章 ：(Chief Medical Technologist)負責醫師簽章 ：( ChiefPhysician )醫 院負責人簽章 ：( Superintendent ) （Name ＆ Signature）（Name ＆ Signature）（Name ＆ Signature）
日期（Date）：本證明三個月內有效（Valid for Three Months）
Appendix: Principles in determining the health status failed
03/06/2012
