ࡱ> vwxy  !"#$%&'()*+,-./012345>789:;<=j?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuz{|}~Root Entry F0$! fSummaryInformation(DocumentSummaryInformation8WordDocumentF  Oh+'0d   ,8@HP\*adminadmin1@(Ee@H fH ՜.+,D՜.+,HPXdlt |* /# 0t|KSOProductBuildVerICV*1033-11.2.0.11516!7497075239F646368FDAEEFD891881520TableZ!Data 6HWpsCustomData Pn<KSKSF0rrEY8rT0   $ ho >"(9  MU GIY KHM SC KHE CA NGI LI XE (Ban hnh km theo Thng t lin tch s 24/2015/TTLT-BYT-BGTVT ngy 21 thng 8 nm 2015 ca B trng B Y t v B trng B Giao thng vn ti) & & ..1& & ... & & ...2& & .. -------CNG HA X HI CH NGH(A VIT NAM c lp - T do - Hnh phc ---------------S: /GKSKLX-....3.... GIY KHM SC KHE CA NGI LI XE nh4 (4 x 6cm)H v tn(ch in hoa):& & & & & & & & & & & & & & & & & & & & & & .. Gii: Nam % N % Tui............................................... S CMND hoc H chiu:& & & & cp ngy& & & /.............../& & & & & . ti& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. Ch  hin ti:& & & & & & & & & & & & & & & & & & & & & & & & & & .  ngh khm sc khe  li xe hng: & & & & & & & & & & & & & & & I. 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, bnh s bn thn: ng (b) /ang mc bnh, tnh trng bnh no sau y khng(Bc s hi bnh v nh du X vo tng ng) C/KhngC/KhngC bnh hay b thng trong 5 nm quai tho ng hoc kim sot tng ng huytC bnh thn kinh hay b thng  uBnh tm thnBnh mt hoc gim th lc (tr trng hp eo knh thuc)Mt thc, ri lon thcBnh  tai, gim sc nghe hoc thng bngNgt, chng mtBnh  tim, hoc nhi mu c tim, cc bnh tim mch khcBnh tiu haPhu thut can thip tim - mch (thay van, bc cu ni, to hnh mch, my to nhp, t slent mch, ghp tim)Ri lon gic ng, ngng th khi ng, ng ri ban ngy, ngy toTng huyt pTai bin mch mu no hoc litKh thBnh hoc tn thng ct sngBnh phi, hen, kh ph thing, vim ph qun mn tnhS dng ru thng xuyn, lin tcBnh thn, lc muS dng ma ty v cht gy nghinNu  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) Hin ti ang c thai hoc nui con nh di 12 thng hay khng?(i vi ph n): ................................................................................................................................... ................................................................................................................................... Ti xin cam oan nhng iu khai trn y hon ton ng vi s tht. Nu sai ti xin chu trch nhim trc php lut.  & & & ..ngy& & & thng& & .nm& & & . Ngi  ngh khm sc khe (K v ghi r h, tn) II. KHM LM SNG Ni dung khmH tn, ch k ca Bc s1. Tm thn: & & & & & & & & & & & & & & & & & & & & & & & & & & .. & & & & & & & & & & & & & & & & & & & & & & & & & & & Kt lun& & & & & & & & & & & & & & & & & & & & & & & 2. Thn kinh: & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & . Kt lun& & & & & & & & & & & & & & & & & & & & & & & & 3. Mt: - Th lc nhn xa tng mt: + Khng knh: Mt phi:& & & & ..Mt tri:& & & . + C knh: Mt phi:& & & & ..Mt tri:& & & . - Th lc nhn xa hai mt: Khng knh& & & C knh& & & & .. - Th trng: Th trng ngang hai mt (chiu mii - thi dng) Th trng ng (chiu trn-di) Bnh thng Hn ch Bnh thng Hn ch -Sc gic + Bnh thng % + M mu ton b % M mu: -  % - Xanh l cy % - vng % Cc bnh v mt (nu c): & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &  & & & & & & & & & & & & & & & & Kt lun& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 4.Tai-Mii-Hng - Kt qu khm thnh lc (c th s dng my tr thnh) + Tai tri: Ni thng:& & ..m; Ni thm:& & & ..m + Tai phi: Ni thng:& & ..m; Ni thm:& & & .. & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & m - Cc bnh v tai mii hng (nu c): & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &  Kt lun& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 5. Tim mch: + Mch: & & & & & & & & ln/pht; + Huyt p:& & & & ../& & & & & & & .mmHg & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & Kt lun& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 6. H hp: & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & Kt lun& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 7. C Xng Khp: & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & ..Kt lun& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 8. Ni tit: & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & ..Kt lun& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 9. Thai sn: & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & ..Kt lun& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &  III. KHM CN LM SNG Ni dung khmH tn, ch k ca Bc s1. Cc xt nghim bt buc: a) Xt nghim ma ty - Test Morphin/Heroin:& & & & & & & & & & & & & & & & & & & - Test Amphetamin:& & & & & & & & & & & & & & & & & & & & - Test Methamphetamin:& & & & & & & & & & & & & & & & & & - Test Marijuana (cn sa):& & & & & & & & & & & & & & & & & .b) Xt nghim nng  cn trong mu hoc hi th:& & & & & & 2. Cc xt nghim ch thc hin khi c ch nh ca bc s khm sc khe: Huyt hc/sinh ha/X.quang v cc xt nghim khc. a)Kt qu:& & & & & & & & & & & & & & & & & & & & & & & & b) Kt lun:& & & & & & & & & & & & & & & & & & & & & & & ...IV. KT LUN & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (Giy khm sc khe ny c gi tr s dng trong vng 06 thng kt ngy k kt lun).  & & & & , ngy& & .thng& .. nm& & . NGI KT LUN (K, ghi r h, tn v ng du) 5. Kt lun sc khe: Ghi r mt trong ba tnh trng sau y: 5.1.  iu kin sc khe li xe hng& & & & & & & & & & & & & & & & & & & 5.2. 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