Ph lc 1

MU GIY KHM SC KHE DNG CHO NGI T 18 TUI TR LN

(Km theo Thng t s 15/2013/TT-BYT ngy 06 thng 5 nm 2013
ca B trng B Y t)
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CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

S: /GKSK-....3.....

GIY KHM SC KHE

H v tn (ch in hoa): ........
nh
(4 x 6cm)

Gii:
Nam
N
Tui:...............................
S CMND hoc H chiu: .......................... cp ngy....../..../..............
ti.
Ch hin ti:.............................
.............................
L do khm sc khe:...............................................................................

TIN S BNH CA I TNG KHM SC KHE

1. Tin s gia nh:
C ai trong gia nh ng (b) mc mt trong cc bnh: truyn nhim, tim mch, i tho
ng, lao, hen ph qun, ung th, ng kinh, ri lon tm thn, bnh khc:
a) Khng

b) C ;
Nu
c,

ngh
ghi
c
th
tn
bnh:.............................................................................................................................
2. Tin s bn thn: ng (b) /ang mc bnh, tnh trng bnh no sau y khng: Bnh
truyn nhim, bnh tim mch, i tho ng, lao, hen ph qun, ung th, ng kinh, ri lon

tm thn, bnh khc: a) Khng

; b) C
Nu c, ngh ghi c th tn bnh: ................
...
3. Cu hi khc (nu c):
a) ng (b) c ang iu tr bnh g khng? Nu c, xin hy lit k cc thuc ang dng v
liu lng:
.
......
b) Tin s thai sn (i vi ph n): .
..
Ti xin cam oan nhng iu
................. ngy .......... thng.........nm................
khai trn y hon ton ng vi s
Ngi ngh khm sc khe
tht theo s hiu bit ca ti.
(K v ghi r h, tn)
I. KHM TH LC
Chiu cao: ...............................cm; Cn nng: ........................ kg; Ch s BMI: ..............................
Mch: ........................ln/pht;
Huyt p:.................... /..................... mmHg
Phn loi th lc:..............................................................................................................................................................
II. KHM LM SNG
1

Tn c quan ch qun ca c s khm sc khe

Tn ca c s khm sc khe
3
Ch vit tt tn c s khm sc khe
2

Ni dung khm
1. Ni khoa
a) Tun hon: ............................................................................................................................................
Phn loi .....................................................................................................................................................
b) H hp: .....................................................................................................................................................
Phn loi ......................................................................................................................................................
c) Tiu ha: ..................................................................................................................................................
Phn loi .....................................................................................................................................................
d) Thn-Tit niu: ....................................................................................................................................
Phn loi ......................................................................................................................................................
) C-xng-khp: ................................................................................................................................
Phn loi ......................................................................................................................................................
e) Thn kinh: ................................................................................................................................................
Phn loi ......................................................................................................................................................
g) Tm thn: .................................................................................................................................................
Phn loi ......................................................................................................................................................
2. Ngoi khoa: ........................................................................................................................................
Phn loi ......................................................................................................................................................
3. Sn ph khoa: ..................................................................................................................................
Phn loi ......................................................................................................................................................
4. Mt:
- Kt qu khm th lc: Khng knh: Mt phi:............. Mt tri: ....................
C knh:
Mt phi: ............. Mt tri: ....................
- Cc bnh v mt (nu c): ..........................................................................................................
- Phn loi: ..................................................................................................................................................
5. Tai-Mi-Hng
- Kt qu khm thnh lc:
Tai tri: Ni thng:.......................... m; Ni thm:.............................m
Tai phi: Ni thng:.......................... m; Ni thm:.............................m
- Cc bnh v tai mi hng (nu c):............................................
- Phn loi: .................................................................................................................................................
6. Rng-Hm-Mt
- Kt qu khm: + Hm trn:..........................................................................................................
+ Hm di: .......................................................................................................
- Cc bnh v Rng-Hm-Mt (nu c)..............................................................................
- Phn loi:.....................................................................................................................................................
7. Da liu: .....................................................................................................................................................
Phn loi:.....................................................................................................................................................

H tn, ch k
ca Bc s
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III. KHM CN LM SNG

H tn, ch k
ca Bc s

Ni dung khm
1. Xt nghim mu:
a) Cng thc mu: S lng HC: .....................................................................................
S lng Bch cu: .......................................................................
S lng Tiu cu:.........................................................................
b) Sinh ha mu: ng mu: ............................................................................................
Ur:..................................................................... Creatinin:.........................................................
ASAT (GOT):.......................................... ALAT (GPT): ...........................................
c) Khc (nu c):...............................................................................................................................

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2. Xt nghim nc tiu:
a) ng: ...............................................................................................................................................
b) Prtin: ..............................................................................................................................................
c) Khc (nu c): .............................................................................................................................

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3. Chn on hnh nh:

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IV. KT LUN
1. Phn loi sc khe:.....................................................4..................................................................................
2. Cc bnh, tt (nu c): ............................................5...................................................................................
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ngy thng nm.................

NGI KT LUN
(K, ghi r h, tn v ng du)

Phn loi sc khe theo loi I hoc II hoc III hoc IV hoc V theo quy nh ti Quyt nh s 1613/BYT - Q
hoc phn loi sc khe theo quy nh ca b tiu chun sc khe chuyn ngnh i vi trng hp khm sc
khe chuyn ngnh
5
Ghi r cc bnh, tt, phng n iu tr, phc hi chc nng hoc gii thiu khm chuyn khoa khm bnh,
cha bnh