‫‪ZA‬‬ ‫‪‬‬ ‫‪ZA‬‬

‫ﺗﺎرﯾﺦ اﻟﯿﻮم ‪.............................................................. :‬‬ ‫رﻗﻢ اﻟﻤﻠﻒ ‪[ ........................................................] :‬‬

‫‪ //‬اﻟﺠﻨﺲ ‪ ........................................... :‬ذﻛﺮ ‪ // ‬أﻧﺜﻰ ‪‬‬ ‫اﻻﺳﻢ ‪............................................................................ :‬‬

‫‪ //‬اﻟﻌﻨﻮان ‪............................................................................. :‬‬ ‫اﻟﻠﻘﺐ ‪............................................................................ :‬‬
‫‪ //‬رﻗﻢ اﻟﮭﺎﺗﻒ ‪....................................................................... :‬‬ ‫ﺗﺎرﯾﺦ اﻟﻤﯿﻼد ] اﻟﻌﻤﺮ [ ‪...................................................... :‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺣﻮل ﻋﻼج ﺳﺎﺑﻖ ﺑﺴﻢ اﻟﻨﺤﻞ‬ ‫ﻣﻌﻠﻮﻣﺎت ﻣﺮﺿﯿﺔ‬

‫‪ // ‬ﻻ ‪‬‬ ‫ﻧﻌﻢ‬ ‫ھﻞ ﺗﻌﺎﻟﺠﺖ ﺑﺴﻢ اﻟﻨﺤﻞ ﻣﻦ ﻗﺒﻞ ‪:‬‬ ‫ﻗﯿﺎس اﻟﻀﻐﻂ ‪............................................... :‬‬
‫اذﻛﺮ اﻟﺴﺒﺐ ‪................................................................................ :‬‬ ‫ﻗﯿﺎس اﻟﺴﻜﺮي ‪............................................. :‬‬
‫ﻧﻌﻢ ‪ // ‬ﻻ ‪‬‬ ‫ھﻞ ﺷﻔﯿﺖ ﻣﻦ اﻟﺤﺎﻟﺔ اﻟﻤﺮﺿﯿﺔ ‪:‬‬ ‫ﻧﻌﻢ ‪ // ‬ﻻ ‪‬‬ ‫)ﻟﻠﻤﺮاة( ھﻞ اﻧﺖ ﺣﺎﻣﻞ ‪:‬‬
‫‪ // ‬ﻻ ‪‬‬ ‫ھﻞ اﻧﺖ ﻣﺼﺎب ﺑﻤﺮض ﻣﻌﺪي ‪ :‬ﻧﻌﻢ‬
‫اذﻛﺮ اﻟﻤﺮض ‪.................................................. :‬‬
‫ﺟﺪول اﻟﺘﻮارﯾﺦ و اﻟﺠﺮﻋﺎت‬

‫اﻟﺘﺮﻛﯿﺰ‬ ‫اﻟﺠﺮﻋﺔ‬ ‫ﺗﺎرﯾﺦ اﻟﺠﻠﺴﺔ‬

‫ﺗﺸﺨﯿﺺ اﻟﺤﺎﻟﺔ اﻟﻤﺮﺿﯿﺔ‬
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‫ﺗﺸﺨﯿﺺ اﻟﺤﺎﻟﺔ ‪............................................... :‬‬
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‫ﻧﻘﺎط اﻟﻌﻼج ‪.................................................... :‬‬
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‫‪...........‬‬ ‫‪ //‬اﯾﺠﺎﺑﻲ ‪‬‬ ‫ﺳﻠﺒﻲ ‪‬‬ ‫اﺧﺘﺒﺎر اﻟﺤﺴﺎﺳﯿﺔ ‪:‬‬
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‫‪.........‬‬ ‫‪...........‬‬ ‫‪............................................................‬‬ ‫ﻋﺪد اﻟﺠﻠﺴﺎت اﻟﻤﻨﺎﺳﺒﺔ ‪...................................... :‬‬

‫‪.........‬‬ ‫‪...........‬‬ ‫‪............................................................‬‬ ‫ﻣﺪة اﻟﻌﻼج اﻟﻤﺤﺘﻤﻠﺔ ‪.......................................... :‬‬

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