ࡱ> \^[U Ubjbjnn .`aa~ n VVVVVjjj8LjCEEEEEE$!iQViVVVVCC1e|/0"o""V\iiod" B :  [ Tn c quan ch qun ca c s khm sc khe] [ Tn ca c s khm sc khe]CNG HA X HI CH NGH(A VIT NAM c lp - T do - Hnh phcS: /GKSK-[ Ch vit tt tn c s khm sc khe]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 ............................................................................ Phn loi ............................................................................. g) Tm thn: ........................................................................ Phn loi ............................................................................ 2. Ngoi khoa: ........................................................................... Phn loi ..................................................................................... 3. Sn ph khoa: .......................................................................  .0XHz''8)X))666.9L9 <><> ?t@v@z@@@@@@@AF0F|HHVJXJ\JtJvJJ*M^MTTTUUUUjhHU hH0JU hH0J"hH0JCJPJ_HaJnHtHhHCJPJ_HaJnHtHhHM IIkdU$$If03$634a$IfIkd$$If03$634a $$Ifa$ $IfgdP $$ a$ p  J "0Zvhx $$Ifa$ $$Ifa$$a$$a$xz^ $$Ifa$$a$Ikd$$If0$634ad !!h"##p$ %%h&''$Ifpkd$$If0$0634a'x(8))66`77n8.9N99$::`; <@<<=8>>?t@x@$If$IfPhn 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)....................................... - 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:.....................................................[Phn loi sc khe theo quy nh ti Quyt nh s 1613/BYT-Q hoc phn loi sc khe theo quy nh ca b tiu chun sc khe chuyn ngnh i vi trng hp khm sc khe chuyn ngnh].................................................................................. 2. Cc bnh, tt (nu c): ............................................[Ghi r cc bnh, tt, phng n iu tr, phc hi chc nng hoc gii thiu khm chuyn khoa  khm bnh, cha bnh]............................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ .....................ngy...... thng......... nm................. 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