aE we Phy lye 1
MAU GIAY KHAM SUC KHOE DUNG CHO NG
(Kem theo Thing te s6 142013 TE-BYT nga 06 thé
U DU 18 TUOL TRO LEN
dim 2013 cua Bo trong Bo ¥ 1¢)
SG Y TE DONG NAL CONG HOA XA HOI CHU NGHIA VIET NAM
. BENH VIEN DA KHOA DONG NAI Doc lip - Ty do - Hanh phic
Sif JAG/GKSK-BYDN
GIAY KHAM SUC KHOE
c a
memes | Ho va ten (chit in hou) - Dé lke.. Lte ies ene eee
Gidi: Nam Uf Nix tdi : 2.
CMND hode Hé chid
Cee. Aa...
Ché 6 hign tai : 44
Phat. tee
Ly do khaim sire khoe
TIEN SU BENH CUA DOI TU 0
1. Tién sir gia dinh:
cap ngay.
tai
Co ai trong gia dinh dng (ba) mac mét trong cac bénh: truyén nhiém, tim mach,
dai thao duong, lao, hen phé quan, ung thu, dé i loan tam than, bénh khic:
a) Khéng (7; b) Co () u “co”, dé nghi ghi cu thé tén bénh:.....
2. Tién str ban than: Ong (ba) di/dang mac bénh, tinh trang bénh nao sau day
khéng: Bénh truyén nhiém, bénh tim mach, dai thio dudng, lao, hen phé quan, ung
thu, déng kinh, rdi loan tém than, bénh khéc: a) Khong (J: b) Co C]
Néu “c6”, dé nghi ghi cy thé tén bénh:
3. CAwhdi khiic (néu 6):
a) Ong (ba) c6 dang diéu tri
ding va ligu lugng:
Néu c6, xin hay lit ké cde thude dang
Tai xin cam doan nhimg.digu Lea Yongay OF thang OLnam SOIL,
Khai trén day hodn to’n ding véi sit
that theo sy hiéu biét ctta ti.
Ngwii dé nghi kham sire khoe
(KY va ghigg ho, tén)
J
Le Yec lan1. KHAM THE LUC
AGL ..em; Can nang:
19. tan/phin; Huyét ép:.. Ade. /..Js.
Phiri loai thé tye! “ML. DD. Can hi F
Il. KHAM LAM SANG
Chieu cao:
Mach: mmHg
CL Ve" Chi sd BMI 21 NG.
ip
Noi dung kham
Ho tén, chit ky
ciia Bac sy
1. Noi khoa
a) Tuan hoan
Phan loai
b) H6 hap:
Phan logi
c) Tiéu hoa:
Phan loai
d) Than-Tiét nigu:
Phaii loai ...
d) Co-xuong-khop:
Phan loai
e) Than kinh:
Phan loai
g) Tam than: ...
Phan lodi .....
2. Ngoai khoa :
Phan loai ...
3. Sin phu khoa :
Phan loai.....
4, Mat:
- Két qua kham thi lye:
Khéng kinh:
Mat phai: ..;
AQ... Mat tdi: 6.10.
C6 kinh:
Mat phai: dC. Mat trai: AOldOA
= Ce bérh vé mat (néu 06): ALP Ledeen.
q..
= Phan loi: sa...Ho tén, chit ky
N@i dung kham Senee
ciia Bae sy
5. Tai-Mai-Hong
- Két qua kham thinh lye:
Tai trai: Noi thuong:. 7
Tai phai: Noi thuéng
- Cae bénh vé tai mili hong (N6,06) Fase
r
|
h
- Phan loai
6. Rang-Ham-Miat
& qua kham: ~ Ham trén
+ Ham dudi
; Qc ee
BS HQ.Th None
Il. KHAM CAN LAM SANG
Ho tén, chit ky
NOi dung kham ctia Bac sf
1. Xét nghiém mau:
a) Céng thite mau: $6 luong HC:
b) Sinh héa mau:
-Uré:
- Creatinin :
- ASAT (GOT): ....
c) Khac (néu c6) :..
PR ALAT (GPT) : «247.29.
2. Xét nghiém nuéc tiéu:
a) Duong ° of ie.
b) Prétéin :
) Khe (M80 6) 5 occecssssesnsentsnerneensNoi dung kham Ho tn, SoG ky
iia Bie sf
3. Chan doan hinh anh:
. | Piel area a Oa
BS: Ha-FhiNgoe
IV. KET LUAN
1. Phan ogi size khde :
2. Cae bénh, tat (néu 6
mf hala. .ngay.ed thang...) nam..2.06
NGUOL KET LUAN
19. ten vei dong dtu)