检查时间：_________________________________________
　　检查地点：_________________________________________
　　检查人姓名、单位、职务：___________________________
　　被检查人姓名、单位、职务：_________________________
　　既往病史：_________________________________________

　　检查情况及结论   

    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________

检查人：____________
办案人：____________
记录人：____________
被检查人：__________
_____年_____月____日