1.xx District (county) xx Street (township) xx City Date of birth, nationality and serial number.

2. ID number, unit or occupation

3. Current address

4. Name of the other party

5, lineal blood relatives, collateral blood relatives within three generations of premarital medical examination results

6, medical advice:

(1) Don't get married.

② It is suggested that it is not suitable for childbearing.

③ It is suggested to postpone marriage.

(4) No medically unsuitable marriage was found.

⑤ It is suggested to take medical measures and respect patients' wishes.

The chief examiner examines the position of the single chapter of medical characteristics.

Contents of pre-marital medical examination certificate form

Date of completion: the date of premarital examination of the client.

ID number: Customer's ID number. If the client is an active serviceman, please fill in the ID number of the serviceman or officer, and indicate the name of the ID card before the number. If the ID card is lost, a certificate shall be issued by the local public security department.

Occupation: Candidates are currently engaged in occupations, such as workers, farmers, teachers, accountants, students, individuals, etc. If you are unemployed or unemployed, please fill in "None".

Education level: the education level of candidates, such as primary school, university, graduate students, etc.

Ethnic group: the ethnic group to which candidates belong, such as Han nationality and Hui nationality.

Account location: the location of the customer account.

Current address: If the current address is inconsistent with the ID card address, please fill in the current address.

Postal Code: the postal code of the current residence.

Work unit: the unit where the customer works. If you are unemployed or unemployed, fill in "None".

Contact number: work or home phone is ok.

Name of the other party: the name of the other party.

Number: consistent with the number of the candidate's pre-marital physical examination certificate.

Counterparty number: consistent with the number of the other party's pre-marital medical examination certificate.

Inspection Date: the date of actual inspection by the customer.

Medical history section:

Circle the options and fill in the details. Past medical history refers to diseases that have been cured before. The current medical history refers to the diseases that are being suffered, including those that have a long course of disease and are still being treated.

1. Blood relationship, past medical history, present medical history: for example, hepatitis B, circle around liver disease, and then fill in "hepatitis B" in other columns. If you choose a congenital disease, you should fill in the specific disease name on the horizontal line. Diseases not indicated in the table are also filled in other columns.

2. Menstrual history: if it is primary amenorrhea, fill in the mark of menarche age; If it is the object of menopause or hysterectomy, fill in the date of menopause or surgery in the last menstrual column, and then indicate menopause or hysterectomy.

3. Previous marriage and childbearing history: The number of abortions includes spontaneous abortion, induced abortion, drug abortion and induced labor.

4. Family history related to heredity: if there is a family history, the relationship between the patient and the object of premarital examination should be indicated.

5. After the medical history inquiry is completed, the client will sign it knowingly. If the client has no writing ability, it will be signed by the guardian.

Physical examination part:

1. No abnormality is found in the physical examination, so you should circle around "None", "Normal" or the corresponding situation; The digital part should be truthfully filled in according to the results of blood pressure, heart rate and other tests.

2. If you have abnormal height and weight, please indicate it in the "Yes" column of special posture.

3. If there is any abnormality, it should be described in detail in the blank; However, the name of the disease cannot be filled in as a test result.

4. There are hearing, vision and language barriers in the column of abnormal facial features.

5. If there is no corresponding column in the physical examination form, please describe the special circumstances found in the inspection in other columns.

Secondary sexual characteristics and genital examination:

According to the inspection results, the inspection results should be circled around the corresponding situation or filled in on the corresponding line, and the name of the disease should not be filled in as the inspection results.

Examiner's signature: comprehensive medical examiners and male and female premarital examiners sign their full names in the signature column after their respective examinations, which cannot be replaced by seals.

Laboratory examination:

1. Paste the comprehensive inspection report of premarital medical examination on the "Inspection Report Paste Sheet" and attach other special inspection reports together with the comprehensive inspection report to the "Premarital Medical Checklist".

2. The inspection results on the inspection report should be filled in with data and words according to the format requirements, and "-","+"or other symbols are not allowed. The words "negative" and "positive" can be handwritten or stamped. The inspector shall sign the full name and fill in the report date.

Inspection results:

1. No abnormality found: if no abnormality is found in the inspection result, mark "√".

2. Abnormal conditions: For abnormal signs and laboratory test results found in medical examination that cannot be used as disease diagnosis, please indicate them in the column of abnormal conditions, such as "hepatomegaly". For the "diagnosed" and "cured" diseases that affect marriage and childbearing, if total hysterectomy is performed due to hysteromyoma, "after total hysterectomy" should still be indicated in the abnormal situation column.

3. Disease diagnosis: If the disease found in the physical examination is "diagnosed" or "incurable", fill in the disease diagnosis column one by one according to the standardized disease diagnosis name and the degree of influence of the disease on marriage and childbirth. All hereditary diseases, although "cured", should be classified as "disease diagnosis" because they are only cured in phenotype and genetic factors have not been eliminated. Although it does not meet the standard of "incurable disease", it should still be included in the column of "disease diagnosis", such as after congenital heart disease surgery.

Medical advice:

Select medical opinions according to the examination results and tick "√" on the corresponding results.

1. It is found that the two sides are lineal blood relatives or collateral blood relatives within three generations, which is medically considered unsuitable for marriage. For example, if one or both parties suffer from severe or extremely severe mental retardation, do not have the ability of marriage awareness, or suffer from serious mental illness, and have aggressive and harmful behaviors during the onset, choose "Suggest not to get married". And signed by the customer.

2. When it is found that there are serious hereditary diseases or other important organ diseases, and it is medically considered that it is not suitable for childbearing, choose "Prompt that it is not suitable for childbearing".

3, found that the designated infectious diseases in the infectious period, mental illness, or other important organ diseases that should be postponed in medicine, choose "suggested to postpone marriage". When giving medical advice on infectious disease patients or pathogen carriers found in premarital examination, they should explain the situation to the subjects and put forward opinions on medical measures such as prevention and treatment. If the parties insist on getting married, they should fully respect the wishes of both parties and indicate that "medical measures are recommended to respect the wishes of the parties".

4. No abnormal conditions or diseases affecting marriage and childbearing were found, and "No medically inappropriate conditions were found" was selected.

Premarital health consultation:

Fill in the consultation content concisely; The consultation content should be based on the examination results and the answers to the questions raised by the subjects, and put forward suggestions on prevention, treatment or other medical measures.

Consultation results:

According to the attitude of both parties to the consultation and guidance, tick "√" in corresponding cases and sign it by both parties. Need to fill in the referral hospital and referral date, as well as the appointment date. After reviewing the results of physical examination and conducting health consultation, the chief physician will issue a certificate of premarital medical examination, fill in the date of issuance and sign the full name.

Note: The Pre-marital Medical Checklist must be completed completely, and the test results cannot be replaced by symbols such as "+"and "-",coined words or homophones, and seals cannot be used instead.

Legal basis:

Marriage registration ordinance

Article 5 Mainland residents who apply for marriage registration shall submit the following documents and supporting materials:

(1) My household registration book and ID card;

(2) A signed statement that I have no spouse and no direct blood relationship with the other party and collateral blood relationship within three generations.

Hong Kong residents, Macao residents and Taiwan Province residents shall submit the following documents and supporting materials when registering for marriage:

(1) My valid passport and ID card;

(2) A statement notarized by the notary office of the place of residence that I have no spouse and no lineal blood relationship with the other party and collateral blood relationship within three generations.

Overseas Chinese applying for marriage registration shall issue the following documents and supporting materials:

(1) my valid passport;

(2) A certificate issued by the notary office or competent authority of the host country and certified by the Chinese people's * * and China's embassy (consulate) in that country that I have no spouse and no lineal blood relatives and collateral blood relatives within three generations, or a certificate issued by the Chinese people's * * and China's embassy (consulate) in that country that I have no spouse and collateral blood relatives within three generations.

Foreigners who register for marriage shall present the following documents and supporting materials:

(a) my valid passport or other valid international travel documents;

(2) A certificate issued by the notary office or competent authority of the host country, and certified by the people of China and the embassy (consulate) of China or the embassy (consulate) of China in that country that I have no spouse, or a certificate issued by the embassy (consulate) of China in that country that I have no spouse.