Phg lpc 1

tvt6u S6 khimsri'c kh6e dtng cho nguiri tir dri ta tuOi tr& I6n
(Kbm theo Ihdn g rr sd I il2 0 I 3/TT-BW ngay 06 thang 5 ndm 20 I 3

"u&i-t @tE-Ee!E)
PHONG KHAM DA KHOA co,NG HOA,XA HO-I CHU NGHIA VIET NAM
Y CAO HOA HONG D6c lAp - Tu do :Hanh phtic
cOxc rY TNHH DIcH vU
Y TE & TM HI-]E LINH

so:,fhJl rcKSK-PKDKYCHH

crAvruAm srlc xuor

,;j Ho vi t€n (chir in hoa): ... .. Llr
Gicri: Nam ENt tr Nam rirrh,,....,/.! .'l',{. .... .....
- . hi f
SO CMND hoac H0 chi;iu: !.2 s:a I[. a azlJ Q
TI
Nfi cfr
"ap,say
Mil
-:l
tai-... ......!.!1s....
:1 Dia chi:. ....1i.....hte.......-- . f.{*.at
1{:t - l

sUBEr{H cua Dor rUgl{G KrIAM suc xsOB

1. Tidn sfr gia tlinh:
Cd ai trong gia dinh 6ng (bd) mic m6t trong ciic bQnh: truy€n nhi6m, tim mach, d6i thSo dulng, lao, hen
ph6 quan, ung thu, dQng kinh, r6i lo4n tdm thAn, b€nh kh6c: a) Kh6ng Etr b) C6 tr; N6u "c6", dA
;
nghi ghi cu thti t€n bQnh:

2. Ti6n sir bin thAn: Ong @e) dd/dang mic bQnh, tinh f4ng bQnh ndo sau ddy kh6ng: Beq truy3:n
nhi6m,'b,Qnh tim m4ch, d6i thrio dulng, lao,'[en phr5 qu6n, ung thu, dQng kinh, r6i loan tdm th6n, bQnh
kh6c: a) Khdng EI b) c6 tr
; N6u "c6l', rlA nghi ghi cg th6 tcn benh: .

3. Cffu hdi khSc (n6u c6):

a) Ong (bd) c6 dang di€u tri b€nh gi khdng? Ndu c6, xin hdy liQt ke c6c thudc dang dtng vd li€u luqng:

b) Tidn sri thai s6n (Ddi vdi php ntr)

Tdi xin cam doan nhirng di6u ugay.Yi. ,hdn{ .8 nam 2o2t
khai tr6n dAy hodn toin dirng v6i sU Ngucri tI6 nghi khdm stfrc kh6e
th6t theo sU hi6u bi6t cria t6i. (Kj,vd ghi rd he, tOn)

9--
t, ,
f:\ D.;!, f{frw
 I

I. KHAM
Chidu cao: 5.} kg; Chi sti gN4t
Mpch: . ,1"??_..... t... 7.k mmHg
PhAn loai th6 l"r*;
II. KHAM LAM SAXC

Hg t6n, ehfr ky cria

B*e
1. NOi khoa:
r- I
aJ Iuan hoan:

b) H6 hdp:

d) Than-Titlt nigu:

BS,si{t,,twffi .,$e {{idn

Phdn logi
e) ThAn kinh:
)
g) TAm thAn: si
PhAn loai
n1{

2. NgoSi khoa: /t\

AI
I I
v-'-I

3. Sin phB khoa: BS,Wffrfr

4.MEt:
- ftjt qui kh6m thi luc: Kh6ng kinh: Uat pnai.)Q/,M Mittrei: ./e'4".
C6 kinh MEt ph6i:
- CAc benh vA mit 1ntlu c6): ............
- PhAn lo4i

5. Tai - Mfii - Hgng:

Tr-h, lfiW
- r6t quikh6m thinh }uc
Tai trSi N6i thulng: N6i
Tai phii: N6i
m; "'- -'f)= :..1T1
m; .m
- Circ bQnh vd tai mfri hgng c6):....
- Phdn lo4i:

6. Ring - Him - Mit:

- KCt qui khdm: + Hlm tr6n:...............
+ Hdm dudi
- C6c bQnh vd Rang-Hdm- Mal (ntiu c6)
ow 2

ll'z
lk
- Phdn lopi:.......
7.Da H6u:
PhAn loAi
*
chr"
 Irr. KtrAM cAN LApr sANG
Hg t6n, che ky
B6c
1. X6t nghifm mau:
a) Cdng thric m6u: S6 luqllg HC
S6 luqng
S6 luqng Ti6u cdu:..
b) Sinh h6a miiu: Duong m6u: .,........
Ur€:. ..-....,i- Creatinin:

2. X6t nghiQm nufc

a) Dulng:

3. ChAn Aoan ninU inh:

Xnr LUriN
Io4i srfrc kh6e (t). I
...........[,u?.t. T-,
e bQnh, tit ( n5u c6) (2). L

..nsdyX!. tnang.0.t. ndm zozt

KET L UAN
,:
va dong dau)'
DA KHOA
rl OA
co N G T Y T
Y
t
*
grri; ,$,i*t

(r):
Ph6n loai sfrc khoe theo guY.girl taiQuy6t dinh s5 l6l3iBYT-QD ho{c phan
loqi suc khoe theo quy rlin6 cua b0 ti6u
khoe chuy€n ngdnli aoi ,oi trudighqp'khrim srrc khoe cfuuydn nginh.