VIETSOVPETRO HEALTH CENTER THE SOCIALIST REPUBLIC OF VIETNAM 2 Pasteur, Vung Tau Vietnam Independence - Freedom - Happiness Phone: (84 - 64) 3857017. Fax 3576833 é — PHIEU KHAM SAC GIAC EYE TEST RECORD Negay kham (Record date):..0.%.1.40.201 2... Ho va tén (Full name) bE... RLEM.... LEAL. a Ngay sinh (Birthday):.d6.J..09.!..4¢84.Sex: Nam (Male) Nir (Female) Chimg minh ND (N a or peso card). Cie. £84000. B03... he BABB LSAO. Quée tich (Nationality): Dia chi (Address): Cong ty (Company) Nehé nghiép (Occupation). Dign thoai (7e):.. 1. Két qua khdm (Examination finding) 11 Thj lye do 6 khoang cach 06 mét (Distance visual Acuity - at 6 meters) | Mat trai (Left Eye) Mat phai (Right Eve) C6 kinh (Corrected) | wy Khéng kinh (Uncorrected) 1.2 Thi lye do gan bang bing test Jaeger - 6 kho’ing cach 30.5em (Near Viswal Acuity - Jaeger test chart at a distance of 30.5 cm) Mat trai (Left Eve) | Milt phai (Right Eye) Cé kinh (Corrected) iy J Khong kinh (Uncorrected) ” bee 1.3 Phan bigt d9 tong phin mau (Color Contrast Differentiation) Dat (Pass) | Khong dat (Fail)| Standard Tuong phan mau (Color Contrast) PAs. ISHIHARA, Bac thang xam (Shade of Gray) [8 PLATE CHART 1.4 C6 can khém thém khéng? co Khéng [] (Is a further examination recommended?) Yes No 2. Chan doan (Diagnosis): 3. Xit tri (Management) BS chuyén khoa méit (Ophthalmologist) Vietsovpetro Health Center Ky, ght 0 ho ten (Name & Signature) AME's name and signature 5 Ip, waa 33 i hl ly Ne —