Noid Phulucl 2 Y KHAM SUC KHOE DUNG CHO NGUOLTU DU 18 TUOLTRO LEN (Kem theo Thong te 66. 14/2013. TT-BYT ngéav-06 thing 5 nd im 2013 cua BG tung BO ¥ 16) CONG HOA XA HOI CHU NGHIA VIET NAM . BENH VIEN BA KHOA DONG NAI Doe lip - Ty do- Ha sée$ly2/GKSK-BVBN GIAY KHAM SUC KHOE Ho va tén (chit hoa) : NGQULEN...DYAW. RAD Giéi : Nam Na O Ls do kham strc khée : A... Aes TIEN SU’ BENH CUA DOI TUQNG KHAM SUC KHOE 1. Tién St gia dinh: C6 ai trong gia dinh dng (ba) mac mét trong cde bs dai théo duxéng, lao, hen phé quan, ung thu, dng kinh, roi log a) Khong fk}; b) Cé []; Néu “cd”, 48 nghi ghi cu thé 2. Tién sir ban than: Ong (ba) da/dang mac bénh, tinh trang bénh nao sau day khéng: Bénh truyén nhiém, bénh tim mach, dai tho dudng, lao, hen phé quan, ung thu, dng kinh, r6i loan tam than, bénh khac: a) Khong [x]; b) Co C] Néu “e6”, dé nghi ghi cu thé tén bénh: 3. Cau hoi khac (néu 1 a) Ong (ba) c6 dang diéu trj bénh gi khong? Néu cd, xin hay list ké cae thude dang ding va ligu lugng: b) Tién str thai san (Doi v6i phy nit):...... Téi xin cam doan nhimg diéu 25q Wu ngay 7. thang.#..ndm®@X... khai trén day hoan toan ding voi su that theo su hiéu biét cua t6i Newoi dé nghj kham stre khoe (KY va ghi rd ho, ten) a Nagy Manh Bag,I. KHAM THE LUC Chiu cao: A720 em; Can nang WY! kes Chi sé BME: S43, Mach: S.Q....lan/phin; Huyét ap. 700/65... mmHg Phan loai thé Ive: DD. Guin Ghee I. KHAM LAM SANG & oat ung kham Ho tén, chi ky ciia Bac sf 1. Ngi khoa a) Tuan hoan: ..... Phan loai b) H6 hap: ..... Phan loai ¢) Tiéu hoa: Phan loai ......... d) Than-Tiét nigu: Phan loai d) Co-xurong-khép FHENAO rls orh-rvc e) Than kinh: Phan loai g) Tam than: Phan log... 2. Ngoai khoa Phan loai 3. San phy khoa : Phan loai .... 4.N ~ Két qua khdm thi lye: Khéng kinh: Mat phai:.40./.<40).... MAt trai: delet. C6 kinh: Mat phai: - Cae bérh vé mt (néu cd): - Phan loai: ......Ho tén, chit ky ciia Bae sf 5. Tai-M - Ket qua khdm thinh lyre: Hong Tai trai: Noi thuron, + PRAM 1OQIS ese ee 6. Ring-Ham-Mat ~ Két qua kham: + Ham wrén : Phan loai:.... “BS HO Thi Ngoe- Ill. KHAM CAN LAM SANG Ho tn, chit ky N@i dung kham dere 1. Xét nghigm mau: a) Cong thtre mau: Sé long HC Sé rong Bach cau : b) Sinh hoa mau: Dudng mau: Ur8 2 iBT. - ASAT (GOT): ..4G:.22........ ALAT (GPT) : 43.2.2... c) Khe (néu cd) : 2. Xét nghigm nurbe tiéu: , a) Duong #00. TM cee rr RAR Sacer b) Protéin : c) Khac (néu BS Ho Thi Non:Ni dung kham Ho ten; ehir ky , ctia Bae sf 3. Chan don hinh anh: nM BRGLBINE TRUONG... er IV. KET LUA 1. Phan logi sire khée : ... 2. Cae bénh, tt (néu c6) + .... 4 déng du) |G PHONG KHTH