Form-1

T.C.
MLL ETM BAKANLII
Salk leri Dairesi Bakanl

OKUL SALII RENC MUAYENE FORMU

Okulu

: ..............................................................

Ad Soyad

: ..............................................................

Numaras

: ..............................................................

Cinsi

Ya

: ..............................................................

Boyu

: ......................................Cm. .................

Arl

: ......................................Kg. ...................

Kan Basnc

PPD

: ......................................mm. ...................

2) Kz:

1) Erkek :

Normal :

Yksek :

Dk :

(............mm. hg.)

GZ MUAYENES

alk

Var :

Grme Keskinlii

Normal

Yok

Solda Grme Zayf :

Dier

Sada Grme Zayf

ki Gzdede Grme Zayf :

: ........................................................(Trahom vb.)

D MUAYENES

rk St Dii Says

: .....................................................

Dolgulu St Dii Says

: .....................................................

rk Kalc Di Says

: .....................................................

Dolgulu Kalc Di Says

: .....................................................

ekilmi Kalc Di Says

Maloklzyon

: .....................................................

: Var :

Yok

Di Fras Kullanma Alkanl : Var :

Yok

FZK MUAYENE

Sal Deri

: Normal
Bit

:
:

Mantar

Dier

Deri

: .....................................................

: Normal

Dier

Kulak

: .....................................................

: Normal

Buon

Perfore Zar

Dier

:.......................................................

Burun

: Normal

Septum Deviasyonu

Dier

: .....................................................

-1-

Boaz

: Normal

Kronik Tonsilit

Boyun

Gs

Nazoferingeal Aknt

Dier

: .................................................

: Normal

Goitre

Dier

: .................................................

: Normal

Deformite (Skolyoz vb.) :

Dier

Akcier

: Normal
Dier

Kalp

: Normal
Dier

Karn

Normal

: .................................................

:
: .................................................

:
: .................................................

rogenital Sistem

Ekstiremite

Hepatomegali

Dier

: .................................................

: Normal

Splenomegali :

Dier

: .................................................

Yry

Topallk

Bozukluu

Atrofi

Dz Tabanlk :

Dier

: .................................................

Varsa Akut Has.

: ............................................................................................

Ruhsal Uyum Durumu

: Uyumlu

Uyumsuz

Deformite

Saptanan Patolojiler

: 1. Yok

A.e Dsa bas. :

ok Uyumsuz :

(retmenin Gzlemine Gre)

SONU

nmemi Tehis

: Normal

Herni

2.
3.
4.
5.

Di Hekimi

Doktor

mza

mza

Not: Bu form, deerlendirmeler bittikten sonra rencilerin kiisel dosyasna konulmak zere okula
braklacaktr.