检查时间：_____年_____月_____日_____时_____分至_____年_____月_____日_____时_____分
检查地点：_______________________________________
检查人姓名、单位、职务：_________________________
办案人姓名、单位、职务：_________________________
被检查人姓名、性别、年龄：_______________________
既往病史：_______________________________________
检查结果及结论：_____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
检查人：__________
办案人：__________
记录人：__________
被检查人__________
_____年___月____日
本笔录看守所留存
