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B Y T CNG HA X HI CH NGHA VIT NAM

S Y t: .................................................. c lp T do Hnh phc


n v: ...................................................

GIY CHNG NHN SC KHE


H v tn (vit ch in hoa): .................................................................................................
nh mu Gii: Nam N Sinh ngy/ thng/ nm ....../ ....../ ..........
(3 4) S CMND hoc h chiu: .................... cp ngy ...../ ....../ .......... ti ................................
H khu thng tr: ............................................................................................................
Ch hin ti: .....................................................................................................................
i tng: 1. Hc sinh, sinh vin 2. Ngi lao ng
Loi hnh khm sc khe: 1. Khi lm h s d tuyn 2. Khi tuyn dng 3. Theo yu cu
L do khm sc khe (ghi c th ngnh, ngh, cng vic... s theo hc hoc lm vic):
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TIN S BNH CA I TNG KHM SC KHE
C ai trong gia nh ng (b) mc mt trong cc bnh sau y khng: Tng huyt p, bnh tim, i tho
ng, lao, hen ph qun, ung th, ng kinh, ri lon tm thn, lit, bnh khc...
1 Khng 2 C Ghi c th tn bnh .......................................................................................................
ng (b) /ang mc bnh, tnh trng no sau y khng?
..............................................................................................................................................................................
Bnh/Tnh trng C Khng Bnh/Tnh trng C Khng
1. Bnh mt, th thc 18. Mt ng
2. Bnh tai, mi, hng 19. Phu thut
3. Bnh tim mch 20. ng kinh
4. Cao huyt p 21. Chng mt/ngt
5. Gin tnh mch 22. Mt thc
6. Hen, vim ph qun 23. Ri lon tm thn
7. Bnh mu 24. Trm cm
8. Bnh i tho ng 25. nh t t
9. Bnh tuyn gip 26. Mt tr nh
10. Bnh tiu ha 27. Ri lon thng bng
11. Bnh thn 28. au u nng
12. Bnh ngoi da 29. Vn ng hn ch
13. D ng 30. au lng
14. Bnh truyn nhim 31. Ht thuc l, nghin ru, ma ty
15. Thot v 32. Ri lon vn ng
16. Bnh sinh dc 33. Ct ct
17. Mang thai 34. Gy xng/trt khp
Nu tr li bt c cu hi no trn l c, ngh m t chi tit:
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Cu hi khc:
35. ng (b) c nhn thy bn thn c bnh tt, vn v sc khe no khng?
ng (b) c cm thy tht s khe mnh v ph hp thc hin cc nhim v c giao
khng? (KSK theo yu cu khng phi tr li cu hi ny).
36. ng (b) c ang ung thuc iu tr no khng?
Nu c, xin hy lit k cc thuc , c v l do dng thuc v liu lng:
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37. ng (b) c tim chng nhng loi vacxin no?
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Ti xin cam oan nhng iu khai trn y hon ton ng vi s tht theo s hiu bit ca ti.
Ch k ca i tng khm sc khe ........................................................... ngy ..... thng ..... nm ..........
I. KHM TH LC
Chiu cao: ....................................................... cm Mch: ...................................................... ln/pht
Cn nng: ......................................................... kg Huyt p: ................................................... mmHg
Vng ngc trung bnh: .................................... cm Nhit : ........................................................... C
Ch s BMI: ........................................................... Nhp th: ................................................. ln/pht
Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
II. KHM LM SNG
1. Tun hon: ....................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
2. H hp: ..........................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
3. Tiu ha: .......................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
4. Thn Tit niu Sinh dc: .........................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
5. Thn kinh: .....................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
6. Tm thn: ......................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
7. H vn ng: .................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
8. Ni tit: .........................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
9. Da liu: ..........................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
10. Sn ph khoa: ................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
11. Mt:
Th lc: Khng knh: Mt phi: ................................................ Mt tri: ...............................................
C knh: Mt phi: ................................................ Mt tri: ...............................................
Cc bnh v mt: .................................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
12. Tai mi hng:
Tai tri: ni thng: ................................. m; ni thm: ...................................... m
Tai phi: ni thng: ................................. m; ni thm: ....................................... m
Bnh v tai mi hng: .........................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
13. Rng hm mt: ..............................................................................................................................................
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Phn loi sc khe: .......................... H tn bc s khm: ......................................... K tn: .........................
III. KHM CN LM SNG
1. Xt nghim mu:
- Cng thc mu: S lng HC: ...................... Bch cu: ................................ Tiu cu: ................................
- ng mu: ......................................................................................................................................................
- Khc (nu c): ..................................................................................................................................................
2. Xt nghim nc tiu:
- ng: ................................ Protein: ................................
- Khc (nu c): ..................................................................................................................................................
..............................................................................................................................................................................
3. Chn on hnh nh:
- X quang tim phi: 1 Bnh thng 2 Khng bnh thng , ghi c th:
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- Khc (nu c): ..................................................................................................................................................
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H tn ngi ghi kt qu cn lm sng: ...................................................................... K tn: .........................
IV. KT LUN
Da vo nhng li khai ca i tng khm sc khe, kt qu khm lm sng v cn lm sng trn y, ti
xc nhn v sc khe ca i tng khm sc khe nh sau:
1. Khe mnh Mc bnh Tn bnh: .........................................................................................................
..............................................................................................................................................................................
2. t sc khe loi: ................................
3. Hin ti /khng sc khe hc tp, lm vic cho ngnh ngh, cng vic (Ghi c th nu c), hng
gii quyt (nu c): .......................................................................................................................................
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Ngy khm sc khe (ngy/thng/nm) ....../ ....../ ..........
Ngy ht hn ca giy chng nhn sc khe (ngy/thng/nm) ....../ ....../ ..........

NGI K GIY CHNG NHN SC KHE


(Chc danh, k tn, ng du v ghi r h tn)