ࡱ> U bjbjnn .aa0 $$i"   8C|t 23033333///1111111$b47H1%0.^/%0%0133u2111%0483311%011113 X1qeY01130231`71`71`71,/LR/61/,/q///111|///23%0%0%0%0`7/////////$ /: ..................... .....................  S: /GKSK-.........CNG HA X HI CH NGH(A VIT NAM c lp - T do - Hnh phc GIY KHM SC KHE H v tn (ch in hoa): & & & & .& & & & & & & & & ...& ....& & & Gii: Nam % N % Tui:............................... S CMND hoc H chiu: .......................... cp ngy....../..../.............. ti& & & & & & & & & & & & . Ch  hin ti:& & & & & & & & & & & & & & .......................& & ...... & & & & & & & .................& ...& & & & & & & .....& & & & & .& & ...& L do khm sc khe:............................................................................... TIN S BNH CA I TNG KHM SC KHE 1. Tin s gia nh: C ai trong gia nh ng (b) mc mt trong cc bnh: truyn nhim, tim mch, i tho ng, lao, hen ph qun, ung th, ng kinh, ri lon tm thn, bnh khc: a) Khng %; b) C %; Nu  c ,  ngh ghi c th tn bnh:............................................................................................................................. 2. Tin s bn thn: ng (b) /ang mc bnh, tnh trng bnh no sau y khng: Bnh truyn nhim, bnh tim mch, i tho ng, lao, hen ph qun, ung th, ng kinh, ri lon tm thn, bnh khc: a) Khng %; b) C % Nu  c ,  ngh ghi c th tn bnh: & & & & & & & & & & & ................& & & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & & & & . 3. Cu hi khc (nu c): a) ng (b) c ang iu tr bnh g khng? Nu c, xin hy lit k cc thuc ang dng v liu lng: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & ..& & & & ..& & & & .& & & & & & & & .& b) Tin s thai sn (i vi ph n): & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & . 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 (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 Ni dung khmH tn, ch k ca Bc s1. Ni khoa a) Tun hon: ............................................................................................................................................ Phn loi ..................................................................................................................................................... b) H hp: ..................................................................................................................................................... Phn loi ...................................................................................................................................................... c) Tiu ha: .................................................................................................................................................. Phn loi ..................................................................................................................................................... d) Thn-Tit niu: .................................................................................................................................... Phn loi ...................................................................................................................................................... ) C-xng-khp: ................................................................................................................................ Phn loi ...................................................................................................................................................... e) Thn kinh: ................................................................................................................................................ Phn loi ...................................................................................................................................................... g) Tm thn: ................................................................................................................................................. Phn loi ...................................................................................................................................................... 2. Ngoi khoa: ........................................................................................................................................ Phn loi ...................................................................................................................................................... 3. Sn ph khoa: .................................................................................................................................. Phn loi ...................................................................................................................................................... 4. Mt: - Kt qu khm th lc: Khng knh: Mt phi:............. Mt tri: .................... C knh: Mt phi: .............Mt tri: .................... - Cc bnh v mt (nu c): .......................................................................................................... - Phn loi: .................................................................................................................................................. 5. Tai-Mii-Hng - Kt qu khm thnh lc: Tai tri: Ni thng:.......................... m;Ni thm:.............................m Tai phi: Ni thng:.......................... m; Ni thm:.............................m - Cc bnh v tai mii hng (nu c):& & ....................................& & & .& .......& & & & - Phn loi: ................................................................................................................................................. 6. Rng-Hm-Mt - Kt qu khm: + Hm trn:.......................................................................................................... + Hm di: ....................................................................................................... - Cc bnh v Rng-Hm-Mt (nu c)..........................................DF\^` : > b d f h | ޡ}uj}u}_Th}htCJ4aJ4h}htCJaJhihtCJaJhtCJaJh=htCJaJ h=hthxrht]h}ht6] h}hth}ht5h}ht5CJ aJ h}ht5CJ \aJ h39 ht5\h39 ht6]jh3UmHnHujh39 ht0JU h39 ht .\`  < > d f j  6 ^gdt$a$gdtQkd$$Ifl0> T$ $644 layt)9$H$If]Ha$gd)9    * h j    6 R T  @ B x 6 ث}k"h39 ht5CJ\aJmHsHht5CJ\aJmHsHhEhtmHsHhtmHsHhtCJaJmHsHhoNhtCJaJmHsH hEhth7OhtCJaJhtCJaJhth}htCJaJh}htCJ4aJ4 h}hth}htCJ$aJ$(  6 b P 8 p2$x$Ifa$gd)9$!$If]`!a$gd)9 $Ifgd)9 b%'gdt$a$gdt $xa$gdt$a$gdt $^a$gdt^gdt6 b RlNPvz  к竟tкeh2thtCJ$aJ$mHsHh*htmHsH"h39 ht5CJ\aJmHsHh*ht5\mHsHhtCJaJmHsHhoNhtCJaJmHsHh2thtmHsHh}htmHsHh}htCJ(aJ(mHsHhtmHsHh39 htmHsHhht5\mHsH' jlp"28^`np&2T`tϛޛvjvjvjvv\h=ht56mHsHh=ht6mHsHh=ht6CJmHsHhDhtCJaJmHsHhtmHsHh=htmHsHh=ht5mHsHh=ht5aJmHsHhhtCJaJmHsHh=htCJaJmHsHhtCJaJmHsHhxrhtmHsHh39 htmHsH$ "$FHZ\`tNP^x|õê|||qhQhtmHsHhtmHsHhTi}htCJaJmHsHhtCJaJmHsHhEhtmHsHh39 htmHsHh39 ht5\mHsHht5\mHsH h=hth=ht6mHsHht6mHsHht5mHsHh=ht5mHsH, "$HR($x$Ifa$gd)9xxgdtgdtVkdJ$$Ifl=0#` t644 layt)9 $$Ifa$gd)9  (Lx 26hĶ|sk`k`kQEQEhtCJaJmHsHhTi}htCJaJmHsHh39 htmHsHhtmHsHht5mHsH h39 hth39 ht6\mHsHh39 ht5\mHsHht5\mHsHh39 ht5mHsHh}ht5\mHsHh39 ht5\mHsHhtmHsHh39 htmHsHhtCJaJmHsHhTi}htCJaJmHsHP \!"#%>&'{{{{{{o{{{{ $$Ifa$gd)9 $Ifgd)9{kd$$Ifl40E%X F t0(44 layt)9  <NPTh>Fhjxz<t(  2 6 b (!.!0!\!`!t!!!!*"b"j"|"~""""""V##########$ $&$$h,8htCJaJmHsHhtmHsHh39 htmHsHhtCJaJmHsHhTi}htCJaJmHsHM$$$$$$$%%%%8%<%%&&&<&>&B&V&v&x&&&''((*"*D+^+,,--/$/&/,0D0J0r111112<222222383:34*4P5ǸǸǸǸǸǸǸǬǸǸǸǘǸǘǸhtmHsHh}ht5mHsHhtCJaJmHsHh}htCJaJmHsHh}htmHsHhtmHsHh39 htmHsHhtCJaJmHsHhTi}htCJaJmHsH<'(*F+,-/,0r11<234P5p55h6(779<9H:f;JXYZ $If^gd)9 $$Ifa$gd)9 $Ifgd)9P5R5d5n5p55 6*6d6666$7p777779929<9^9r999F:|:~:::;X;d;j;;;;<XJXbXYYZZZZ\\\&\l\p\\ۼۼбۯۼۢۓhtCJaJmHsHhihtCJaJmHsHh}htCJmHsHUh0htmHsHhtCJaJmHsHhtmHsHh}htmHsHh}htCJaJmHsHht5mHsHh}ht5mHsH5.................................... - Phn loi:..................................................................................................................................................... 7. Da liu: ..................................................................................................................................................... Phn loi:..................................................................................................................................................... .............................................................................................................................. .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .............................................................................................................................. .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .............................................................................................................................. .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... ..........................................III. KHM CN LM SNG Ni dung khmH tn, ch k ca Bc s1. Xt nghim mu: a) Cng thc mu: S lng HC: ..................................................................................... S lng Bch cu: ....................................................................... S lng Tiu cu:......................................................................... b) Sinh ha mu: ng mu: ............................................................................................ Ur:..................................................................... Creatinin:......................................................... ASAT (GOT):.......................................... ALAT (GPT): ........................................... c) Khc (nu c):............................................................................................................................... ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ 2. Xt nghim nc tiu: a) ng: ............................................................................................................................................... b) Prtin: .............................................................................................................................................. c) Khc (nu c): ............................................................................................................................. ................................................ ................................................ ................................................ 3. Chn on hnh nh: .......................................................................................................................................................................... .......................................................................................................................................................................... ................................................ ................................................ ................................................ IV. KT LUN 1. Phn loi sc khe:....................................................................................................................................... 2. 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