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B Y T

S Y T TP.H CH MINH
N V Y T .....

CNG HA X HI CH NGHA
VIT NAM
c Lp - T Do - Hnh Phc

GIY CHNG NHN SC KHE


(iu khin cc phng tin giao thng c gii)

HNH
2X3

H v tn: .............................................................B danh:................................


Ngy thng nm sinh: .........................................................................................
C quan cng tc:................................................................................................
Qu qun:.............................................................................................................
Ni KHK thng tr: .......................................................................................

I.
TIU S BN THN
.............................................................................................................................................
.............................................................................................................................................
II.

KHM

1.

Th lc:
Chiu cao:
cm...................................Cn nng:
kg
Vng ngc trung bnh: cm
Lc bp tay thun: .............................................kg
Tay khng thun:................................................kg
Lc ko thn: kg
2.
Mt:
Th lc: Mt phi khng knh..................: c knh

3.
4.
-

Mt tri khng knh.........................: c knh


Knh loi:........................................: s .................................................
Sc gic: .................................................................
Bnh mt: ............................................................
Tai Mi - Hng:
Tay phi nghe ni thng cch ..............................
m, nghe ni thm th cch....................................m
Tay tri nghe ni thng cch ...............................
m, nghe ni thm th cch....................................m
Bnh tai: .................................................................
Bnh mi: ...............................................................
Bnh hng: .............................................................
Rng hm mt:
Hm trn: ...............................................................

Hm di: ..............................................................
Tm thn kinh:
ng kinh: ................................................ T lit: ......................................................
Phn x: Tay
Chn
Cc bnh v thn kinh :.................................................................................................
Cc bnh v tm thn :..................................................................................................
6.
Tun hon:
o ln 1
o ln 2
Mch:
o ln 1
o ln 2

5.

Huyt p ti a ............o ln 3 ........ti thiu ...............o ln 3 ......................


Bnh tim: ................................................................
Bnh mch mu: ....................................................
7.
Vn ng:
Khp: .....................................................................
Xng c: ..............................................................
8.
Cc bnh khc:
H hp: ...................................................................
Tiu ha: ................................................................
Tit niu sinh dc: ..................................................
Bnh ngoi da hoa liu: ..........................................
Cc b phn khc: ..................................................
9.
Cc xt nghim cn lm sng:..........................................
.......................................................................................................................................

III.

KT LUN
(C iu kin sc khe iu khin cc phng tin giao thng c gii khng?
iu khin c loi phng tin no?)
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Ngy...... Thng....... Nm.......
Trng on khm
(K tn, ng du, ghi r h tn)

Ghi ch: Cc bc s khm sc khe cp giy chng nhn cho ngi iu khin
cc phng tin giao thng c gii cn nghin cu k Tiu chun sc khe ngi iu
khin cc phng tin giao thng c gii c ban hnh theo quyt nh s:
4132/Q-BYT ngy 04 thng 10 nm 2001 ca B Y T.