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H v tn b, m hoc ngi gim h:........................................... & & & & & & & & ...& .................& & & & & & & & & & & & & ...& Ch  hin ti:& & & & & & & & & & .............& & & & & & & ...... & & & & & & & & ...& & .................& & & & & & & & & & & & ...& L do khm sc khe:......................................................................... ................................................................................................................... ................................................................................................................... TIN S BNH TT 1. Tin s gia nh: C ai trong gia nh (ng, b, b, m, anh ch em) mc cc bnh bm sinh hoc bnh truyn nhim: Khng % C % Nu  c ,  ngh ghi c th tn bnh:................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... 2. Tin s bn thn: a) Sn khoa: - Bnh thng. - Khng bnh thng:  thiu thng;  tha thng;  c can thip;  ngt, M b bnh trong thi k mang thai (nu c cn ghi r tn bnh:& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & & & & & & & & & & & & & & ...& & & & & & & & & & & & ..& & ) b) Tim chng: STTLoi vc xinTnh trng tim/ung vc xinCKhngKhng nh r1BCG2Bch hu, ho g, un vn3Si4Bi lit5Vim no Nht Bn B6Vim gan B7Cc loi khcc) Tin s bnh/tt: (cc bnh bm sinh v mn tnh) - Khng % - C % Nu  c , ghi c th tn bnh& & & & & & ..& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . d) Hin ti c ang iu tr bnh g khng? Nu c, ghi r tn bnh v lit k cc thuc ang dng: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . Ti xin cam oan nhng iu khai trn y hon ton ng vi s tht theo s hiu bit ca ti. ................. ngy .......... thng.........nm............ Ngi  ngh khm sc khe (hoc Cha/m hoc ngi gim h) (K v ghi r h, tn)  I. KHM TH LC Chiu cao:...............................cm; Cn nng:........................ kg;Ch s BMI:.............................. Mch: ........................ln/pht; Huyt p:.................... /..................... mmHg Phn loi th lc:.............................................................................................................................................................. II. KHM LM SNG 1. Nhi khoa a) Tun hon: .......................................................................................................... ..................................................................................................................................... b) H hp: ................................................................................................................ ...................................................................................................................................... c) Tiu ha: .............................................................................................................. ..................................................................................................................................... H tn, ch k ca Bc s ................................ ................................ ................................ ................................ ................................  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Tai-Mii-Hng a) Kt qu khm thnh lc: Tai tri: Ni thng:.......................... m;Ni thm:.............................m Tai phi: Ni thng:.......................... m; Ni thm:.............................m b) Cc bnh v Tai-Mii-Hng (nu c):& & ....................................& & & .& ..& & & & .................................................................................................................................................................................. 4. Rng-Hm-Mt a) Kt qu khm: + Hm trn:....................................................................................................... + Hm di: .................................................................................................... b) Cc bnh v Rng-Hm-Mt (nu c)........................................................................... ................................................................................................................................................................................................................. ............................................................................................................................. .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .............................................................................................................................. .......................................... .......................................... .......................................... ........................................................................................................................................................................III. KHM CN LM SNG Ni dung khmH tn, ch k ca Bc sXt nghim huyt hc/sinh ha/Xquang v cc xt nghim khc khi c ch nh ca bc s: Kt qu:..................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ............................... ............................... ............................... ...............................IV. KT LUN CHUNG Sc khe bnh thng......................................................................................... 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