B Y T

*****
S: 13/2007/TT-BYT

CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
******
H Ni, ngy 21 thng 11 nm 2007

THNG T
HNG DN KHM SC KHE
Cn c Ngh nh s 49/2003/N-CP ngy 15/5/2003 ca Chnh ph quy nh chc
nng, nhim v, quyn hn v c cu t chc ca B Y t;
Cn c B Lut Lao ng ngy 23 thng 6 nm 1994 v B Lut Lao ng sa i, b
sung ngy 02 thng 4 nm 2002;
Cn c Ngh nh s 06/CP ngy 20/1/1995 ca Chnh ph quy nh chi tit mt s iu
ca B Lut lao ng v an ton lao ng v v sinh lao ng; Ngh nh s
110/2002/N-CP ngy 27/12/2002 ca Chnh ph v vic sa i, b sung mt s iu
ca Ngh nh s 06/CP ngy 20 thng 01 nm 1995 ca Chnh ph quy nh chi tit mt
s iu ca B Lut Lao ng v an ton lao ng v v sinh mi trng,
B Y t hng dn vic khm sc khe nh sau:
I. PHM VI IU CHNH V I TNG P DNG
1. Thng t ny hng dn khm sc khe khi lm h s d tuyn, khm sc khe khi
tuyn dng, khm sc khe nh k v khm sc khe theo yu cu.
2. i tng p dng
Thng t ny c p dng i vi cc tp th v c nhn sau y:
a) C s s dng ngi lao ng, c s o to, dy ngh.
b) Hc sinh, sinh vin v hc vin lm h s d tuyn hoc ang hc ti cc c s gio
dc quc dn, dy ngh; ngi lao ng lm h s xin c tuyn dng, ngi lao
ng khi c tuyn dng, ngi lao ng ang lm vic ti cc c s s dng ngi lao
ng v ngi c nhu cu khm sc khe (sau y gi chung l i tng khm sc
khe).
c) Cc c s y t cng lp v ngoi cng lp iu kin c khm sc khe quy nh
ti Thng t ny tham gia khm sc khe khi lm h s d tuyn, khm sc khe khi
tuyn dng, khm sc khe nh k v khm sc khe theo yu cu (sau y gi chung l
c s khm sc khe).
3. Thng t ny khng p dng trong vic khm bnh ngoi tr, ni tr trong cc c s
khm bnh, cha bnh; khng p dng i vi cc i tng tham gia khm tuyn ngha
v qun s, tuyn sinh qun s, khm tuyn cng an, tuyn sinh cng an, khm sc khe

cho ngi Vit Nam i lao ng nc ngoi v ngi nc ngoi lao ng ti Vit
Nam, khm gim nh y khoa, gim nh php y tm thn.
II. GII THCH T NG
1. Khm sc khe khi lm h s d tuyn l khm sc khe cho hc sinh lm h s d
tuyn vo cc hc ti cc c s gio dc quc dn, dy ngh; ngi lm h s d thi
ly bng li xe v ngi lao ng lm h s xin c tuyn dng vo lm vic ti cc
c s s dng ngi lao ng.
2. Khm sc khe khi tuyn dng l khm sc khe cho hc sinh, sinh vin v hc vin
khi trng tuyn vo hc ti cc c s gio dc quc dn, dy ngh; ngi lao ng khi
c tuyn dng vo lm vic ti cc c s s dng lao ng.
3. Khm sc kho nh k l khm sc kho cho hc sinh, sinh vin, hc vin v ngi
lao ng quy nh theo thi gian: 1 nm mt ln hoc 6 thng mt ln i vi cc ngh,
cng vic nng nhc, c hi, nguy him.
4. Khm sc khe theo yu cu l khm sc khe cho ngi c nhu cu, t nguyn mun
kim tra sc khe.
III. IU KIN I VI C S KHM SC KHE
1. C cc bc s khm cc chuyn khoa: Ni, ngoi, sn ph khoa, mt, tai mi hng,
rng hm mt; c cc bc s hoc k thut vin lm cc xt nghim mu, xt nghim nc
tiu. X quang.
2. C nng lc chuyn mn, k thut lm cc xt nghim c bn
- Xt nghim mu: Cng thc mu, ng mu.
- Xt nghim nc tiu: ng niu, protein niu.
- X quang tim phi.
3. C c s vt cht, trang thit b theo Quy nh c s vt cht v trang thit b c
bn phc v cho khm sc khe c quy nh ti Ph lc s 1 ban hnh km theo
Thng t ny.
i vi cc c s y t cha cc trang thit b theo quy nh ti Ph lc s 1, c th kt
hp (thng qua hnh thc hp ng lin kt) vi cc c s y t c c s vt cht, trang
thit b theo Ph lc s 1 t chc khm sc khe theo quy nh ti Thng t ny.
IV. T CHC KHM SC KHE
1. Quy nh chung

a) Hc sinh, sinh vin lm h s d tuyn vo hc ti cc c s gio dc quc dn, dy

ngh, ngi lm h s d thi ly bng li xe v ngi lao ng lm h s xin c
tuyn dng vo lm vic ti cc c s s dng lao ng phi c khm sc khe khi
lm h s d tuyn.
b) Hc sinh, sinh vin v hc vin khi c tuyn vo hc ti cc c s o to, dy ngh
hoc ngi lao ng c tuyn dng vo lm vic ti c s s dng lao ng phi c
khm sc khe khi tuyn dng. Trong trng hp giy chng nhn sc khe khi lm h
s d tuyn cn gi tr th khng nht thit phi khm sc khe khi tuyn dng.
c) Hc sinh, sinh vin ang hc ti cc c s gio dc quc dn, dy ngh hoc ngi lao
ng lm vic ti cc c s s dng lao ng phi c khm sc khe nh k t nht 1
ln trong 1 nm. i vi cc ngh, cng vic nng nhc, c hi, nguy him th thi gian
khm sc khe nh k theo quy nh ca ngh v ca cng vic .
d) C s khm sc khe cn c vo l do khm sc khe: khi lm h s d tuyn, tuyn
dng, nh k, theo yu cu v Bng tiu chun sc khe ca ngi lao ng, hc sinh,
sinh vin hin hnh c thc hin khm sc khe.
) i vi cc ngh, cng vic c tiu chun sc khe ring, th c s khm sc khe
phi thc hin cc quy nh ca tiu chun .
e) Giy chng nhn sc khe khi lm h s d tuyn, khi tuyn dng v khm sc khe
theo yu cu p dng theo mu c quy nh ti Ph lc s 2 ban hnh km theo Thng
t ny. Giy chng nhn sc khe c ng du gip lai ca c s khm sc khe, c
gi tr trong vng 12 thng k t ngy k.
g) S khm sc khe nh k p dng theo mu quy nh ti Ph lc s 3 ban hnh km
theo Thng t ny (kh giy A4, 1 s c 12 t) c p dng i vi khm sc khe nh
k.
h) Ngi kt lun v k giy chng nhn sc khe, s khm sc khe nh k l Th
trng c s khm sc khe hoc ngi c Th trng c s khm sc khe y quyn
v phi chu trch nhim v kt lun ca mnh.
i) Ph khm sc khe
- i vi khm sc khe khi lm h s d tuyn, khi tuyn dng, khm sc khe theo
yu cu do i tng khm sc khe np ph theo mc ph thu vin ph hin hnh.
- i vi khm sc khe khi tuyn dng, khm sc khe nh k cho hc sinh, sinh vin,
hc vin, ngi lao ng (khm sc khe tp trung) th c s s dng lao ng np ph
theo mc thu vin ph hin hnh. i vi khm sc khe nh k n l, ph khm sc
khe do i tng khm sc khe trc tip chi tr v c s gio dc cng dn, dy ngh,
c s s dng lao ng thanh ton ph khm sc khe cho i tng khm sc khe.

k) Khm sc khe l hot ng chuyn mn, phi c lu tr, thng k, bo co vo

hot ng chung ca c s y t.
2. Th tc khm sc khe
a) Khm sc khe khi lm h s d tuyn, khm sc khe khi tuyn dng th i tng
khm sc khe phi np nh mu c 4 x 6cm (nh chp trong vng 6 thng gn nht), s
lng nh ty theo s lng giy chng nhn sc khe do i tng khm sc khe yu
cu.
b) Khm sc khe nh k
- i vi khm sc khe tp trung: C s gio dc quc dn, dy ngh, c s s dng lao
ng cn xut trnh H s sc khe. H s sc khe gm giy chng nhn sc khe khi
tuyn dng (i vi khm sc khe nh k ln u), s khm sc khe nh k, cc kt
qu khm cha bnh khc (nu c).
- i vi khm sc khe n l: i tng khm sc khe cn xut trnh thm giy gii
thiu ca n v ngh khm sc kho nh k.
c) Khm sc kho theo yu cu: i tng khm sc khe cn xut trnh giy Chng
minh th nhn dn hoc giy t ty thn c nh ng du gip lai (nh h chiu, bng li
xe). Nu khng c Chng minh th nhn dn hoc giy t ty thn, phi c nh mu c 4
x 6cm dn vo cc giy chng nhn sc khe (nh chp trong vng 6 thng gn nht).
3. T chc khm sc khe
Theo 2 hnh thc:
- Khm sc khe tp trung: Cc c quan, n v c nhu cu khm sc khe khi tuyn
dng, khm sc khe nh k cho cc i tng, lin h v k hp ng vi c s khm
sc khe t chc khm sc khe cho cc i tng ti c s khm sc khe hoc ti
c quan, n v.
- Khm sc khe n l: Do i tng khm sc khe lin h trc tip vi c s khm
sc khe c khm sc khe ti c s y t.
4. Quy trnh khm sc khe
a) Tip nhn h s v hon thnh cc th tc hnh chnh
i tng khm sc khe c trch nhim cung cp y , chnh xc, trung thc cc
thng tin c nhn, tnh trng sc khe hin ti, tin s bnh tt ca bn thn v gia nh
trong phn tin s ca i tng khm sc khe (theo mu giy chng nhn sc khe).
b) Khm th lc

o chiu cao, cn nng, vng ngc trung bnh, ch s BMI, mch, nhit, nhit , huyt
p v nhp th.
c) Khm lm sng ton din theo cc chuyn khoa
d) Khm cn lm sng
- Cn lm sng bt buc:
+ Cng thc mu, ng mu.
+ Xt nghim nc tiu: tng phn tch nc tiu (ng, protein, t bo).
+ Chp X quang tim phi thng, nghing. Ring i vi trng hp khm sc khe
nh k, chiu hoc chp X quang tim phi c thc hin theo ch nh ca bc s lm
sng.
- Cn lm sng khc: i tng khm sc khe phi c lm thm cc xt nghim cn
lm sng khc khi c ch nh ca bc s lm sng; hoc yu cu ca c s gio dc quc
dn, dy ngh, c s s dng lao ng; hoc yu cu ca i tng khm sc khe.
) i vi khm sc khe theo yu cu, cc ni dung khm lm sng, cn lm sng c
thc hin theo yu cu ca i tng khm sc khe v c s t vn ca bc s khm
bnh.
e) Cc bc s khm lm sng phi phn loi sc khe, k v ghi r h tn vo giy chng
nhn sc khe, s khm sc khe nh k v phi chu trch nhim v kt lun ca mnh.
Ngi ghi cc kt qu cn lm sng phi k v ghi r h tn vo giy chng nhn sc
khe, s khm sc khe nh k.
g) Cn c vo kt qu khm lm sng v cn lm sng, ngi c thm quyn hoc ngi
c y quyn k giy chng nhn sc khe, s khm sc khe nh k kt lun:
- i vi khm sc khe khi lm h s, khi tuyn dng: khe mnh hay mc bnh (ghi c
th tn bnh); xp loi sc khe; hin ti hay khng sc khe hc tp, lm vic
cho ngnh ngh, cng vic (ghi c th tn ngh, cng vic nu c th).
- i vi khm sc khe theo yu cu: Hin ti khe mnh hay mc bnh (ghi c th tn
bnh), hng iu tr.
- i vi khm sc khe nh k: ngoi kt lun khe mnh hay mc bnh (ghi c th tn
bnh); xp loi sc khe; hin ti hay khng sc khe hc tp, lm vic cho
ngnh ngh, cng vic (ghi c th tn ngh, cng vic nu c th), cn c ch nh iu
tr, phc hi chc nng, khm chuyn khoa iu tr bnh, khm bnh ngh nghip (nu
c), yu cu c s s dng lao ng chuyn cng vic khc ph hp (nu khng tiu
chun sc khe).

h) Giy chng nhn sc khe khi lm h s d tuyn c lm thnh 2 bn tr ln (ty

theo yu cu ca i tng khm sc khe); giy chng nhn sc khe khi tuyn dng,
giy chng nhn sc khe khi khm theo yu cu c lm thnh 1 bn, c ng du ca
c s khm sc khe. C s khm sc khe tr giy chng nhn sc khe cho i tng
khm sc khe hoc c s gio dc quc dn, dy ngh, c s s dng lao ng.
S khm sc khe nh k c tr cho i tng khm sc khe i vi khm sc khe
n l hoc tr cho c s gio dc quc dn, dy ngh, c s s dng lao ng i vi
khm sc khe tp trung.
i) Tr giy chng nhn sc khe, s khm sc khe nh k
- i vi trng hp khm sc khe n l: tr ngay trong ngy lm vic.
- i vi trng hp khm sc khe tp trung: tr trong vng 10 ngy lm vic (hoc
theo hp ng tha thun gia c s khm sc khe vi c s gio dc quc dn, dy
ngh, c s s dng lao ng).
k) Thanh l hp ng khm sc khe vi c s gio dc quc dn, dy ngh, c s s
dng lao ng (nu c).
V. T CHC THC HIN
1. Cc c s gio dc quc dn, dy ngh, c s s dng lao ng c trch nhim t chc
khm sc khe khi tuyn dng, khm sc khe nh k cho hc sinh, sinh vin, hc vin
v ngi lao ng theo quy nh.
2. Hc sinh, sinh vin, hc vin v ngi lao ng c trch nhim i khm sc khe khi
lm h s d tuyn, khm sc khe khi tuyn dng, khm sc khe nh k.
3. Cc c s y t cng lp v ngoi cng lp nu c iu kin i vi c s khm sc
khe c quy nh ti Mc III ca Thng t ny, Th trng n v quyt nh vic t
chc khm sc khe khi lm h s d tuyn, khm sc khe khi tuyn dng, khm sc
khe nh k v khm sc khe theo yu cu. ng thi, n v phi bo co v S Y t
cc tnh, thnh ph trc thuc trung ng (i vi cc n v trc thuc S, n v y t t
nhn ng trn a bn); y t cc B ngnh (i vi cc n v trc thuc B, Ngnh); B
Y t - V iu tr (i vi cc n v trc thuc B).
4. B Y t (V iu tr), S Y t cc tnh, thnh ph trc thuc Trung ng, Y t cc B,
Ngnh c trch nhim kim tra vic thc hin khm sc khe ca cc c s khm sc
khe theo ng cc quy nh.
VI. IU KHON THI HNH
Thng t ny c hiu lc sau 15 ngy, k t ngy ng cng bo.

Trong qu trnh thc hin, nu c kh khn vng mc ngh phn nh v B Y t (V

iu tr) c nghin cu gii quyt./.

KT. B TRNG
TH TRNG
Ni nhn:
- Vn phng Trung ng ng v cc Ban ca ng;
- C quan TW ca cc on th;
- Vn phng Quc hi;
- Vn phng Chnh ph; Cng bo (2 bn), Website;
- B T php (Cc kim tra vn bn);
- Cc B, c quan ngang B, c quan thuc Chnh ph;
- B Y t: + B trng, Th trng,
+ Cc Cc, V, Vn Phng, thanh tra;
+ Cc n v thuc B Y t;
+ Website B Y t;
- S Y t cc tnh, thnh ph trc thuc TW;
- Y t cc B, Ngnh;
- Lu: VT, Tr, PC.

Nguyn Th Xuyn

PH LC S 1
QUY NH C S VT CHT V TRANG THIT B Y T C BN PHC V
CHO KHM SC KHE
(Ban hnh km theo Thng t s 13/2007/TT-BYT ngy 21/11/2007 ca B trng B Y
t)
TT
I
1.
2.
3.
4.
II
1.
2.
3.
4.
5.
6.
7.
8.

Ni dung
C s vt cht
Phng khm a khoa
Phng khm chuyn khoa: Ni, ngoi, sn ph khoa, mt, tai mi
hng, rng hm mt
Phng chp X quang
Phng xt nghim
Trang thit b c bn
T h s bnh n
T thuc cp cu
B bn gh khm bnh
Ging khm bnh
Gh ch khm
T sy dng c
Ni luc, kh trng dng c y t
Cn c thc o chiu cao

S lng
01
06
01
01
01
01
02
02
10
01
01
01

9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23
24.
25.
26.
27.

Thc dy
ng nghe bnh ngi ln
Huyt p k ngi ln
Nhit k y hc 420C
n c phim X quang
Ba th phn x
B khm da (knh lp)
n soi y mt
Hp knh th th lc
Bng kim tra th lc
Bng th thc mu
B khm tai mi hng: n soi, 20 b dng c, khay ng
B khm rng hm mt
Bn khm v b dng c khm ph khoa
My phn tch sinh ha
My phn tch huyt hc
My phn tch nc tiu
B dng c th nc tiu
My X quang

02
02
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01

PH LC S 2
MU GIY CHNG NHN SC KHE
( Ban hnh km theo Thng t s 13/2007/TT-BYT ngy 21/11/2007 ca B trng B Y
t)
B Y T
S Y t:

CNG HA X HI CH NGHA VIT

NAM
c lp T do Hnh phc
*******

n v:

GIY CHNG NHN SC KHE

nh mu

H v tn (vit ch in hoa):

(4 x 6cm)

Gii:

Nam

Sinh ngy/thng/nm .../.../........

S CMND hoc h chiu: ......... cp ngy........../......./....... ti.......

H khu thng tr:
Ch hin ti:
i tng : 1. Hc sinh, sinh vin

2. Ngi lao ng

Loi hnh khm sc khe: 1. Khi lm h s d tuyn 2. Khi tuyn dng 3. Theo yu
cu
L do khm sc khe (ghi c th ngnh, ngh, cng vic s theo hc hoc lm vic):
...............................................................................................................................
...............................................................................................................................
TIN S BNH CA I TNG KHM SC KHE
C ai trong gia nh ng (b) mc mt trong cc bnh sau y khng: Tng huyt p,
bnh tim, i tho ng, lao, hen ph qun, ung th, ng kinh, ri lon tm thn, lit,
bnh khc
1 - khng

2 c Ghi c th tn bnh ..............................................................

ng (b) / ang mc bnh, tnh trng no sau y khng?

..........................................................................................................................................
Bnh/tnh trng
1. Bnh mt, th thc
2. Bnh tai, mi, hng
3. Bnh tim mch
4. Cao huyt p
5. Gin tnh mch
6. Hen, vim ph qun
7. Bnh mu
8. Bnh i tho ng
9. Bnh tuyn gip
10. Bnh tiu ha
11. Bnh thn
12. Bnh ngoi da
13. D ng
14. Bnh truyn nhim

khng

15. Thot v

Bnh/tnh trng
18. Mt ng
19. Phu thut
20. ng kinh
21. Chng mt/ngt
22. Mt thc
23. Ri lon tm thn
24. Trm cm
25. nh t t
26. Mt tr nh
27. Ri lon thng bng
28. au u nng
29. Vn ng hn ch
30. au lng
31. Ht thuc l, nghin ru,
ma ty
32. Ri lon vn ng

khng

16. Bnh sinh dc

17. Mang thai

33. Ct ct
34. Gy xng/trt khp

Nu tr li bt c cu hi no trn l c, ngh m t chi tit:

................................................................................................................................
................................................................................................................................
Cu hi khc:
35. ng (b) c nhn thy bn thn c bnh tt, vn sc khe no
khng?
ng (b) c cm thy tht s khe mnh v ph hp thc hin cc
nhim v c giao khng? (KSK theo yu cu khng phi tr li cu
hi ny).
36. ng (b) c ang ung thuc iu tr no khng?

................................................................................................................................
................................................................................................................................
37. ng (b) c tim chng nhng loi vacxin no?
................................................................................................................................
................................................................................................................................
Ti xin cam oan nhng iu khai trn y hon ton ng vi s tht theo s hiu bit
ca ti.
Ch k ca i tng khm sc khe ................ngy....thng....nm......
I. KHM TH LC
Chiu cao:

__________ cm

Mch:________ ln/pht

Cn nng:

__________ kg

Huyt p:_____ /_______ mmHg

Vng ngc trung bnh:________ cm

Nhit :______ 0C

Ch s BMI:

Nhp th: _____ ln/pht

__________

Phn loi sc khe: __________ H tn bc s khm:

II. KHM LM SNG

________ k tn:__

1. Tun
hon:________________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
2. H
hp:__________________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
3. Tiu
ha:_________________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
4. Thn Tit niu sinh
dc:__________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____

Phn loi sc khe: ________________ H tn bc s khm:_____________ k

tn:____
5. Thn
kinh:________________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
6. Tm
thn:________________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
7. H vn
ng:______________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
8. Ni
tit:__________________________________________________________________
_______________________________________________________________________
____

_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
9.Da
liu:___________________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
10. Sn ph
khoa:____________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
11. Mt
Th thc: Khng knh: Mt phi: _______ Mt tri: ______________________
C knh

Mt phi: _____ Mt tri:______________________

Cc bnh v
mt:____________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____

Phn loi sc khe: ________________ H tn bc s khm:_____________ k

tn:____
12. Tai mi hng:
Tai tri:

ni thng:________ m;

Tai phi:

ni thng:________ m;

ni thm: _________________ m
ni thm: _________________ m

Bnh v tai mi
hng:_________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
13. Rng Hm Mt:
_______________________________________________________________________
____
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
III. KHM CN LM SNG
1. Xt nghim mu
- Cng thc mu: S lng HC: ____________ Bch cu: _________ Tiu
cu_________
- ng mu
_______________________________________________________________

- Khc (nu c)
______________________________________________________________
2. Xt nghim nc tiu:
- ng: _______________________________ Protein: __________________
- Khc (nu c) ....................................................................................................................
..............................................................................................................................................
3. Chn on hnh nh
- X quang tim phi: 1 Bnh thng

2 Khng bnh thng , ghi c th:

_______________________________________________________________________
____
- Khc (nu c) ....................................................................................................................
..............................................................................................................................................
H tn ngi ghi kt qu cn lm sng: _____________________ K tn:
_____________
IV. KT LUN
Da vo nhng li khai ca i tng khm sc khe, kt qu khm lm sng v cn lm
sng trn y, ti xc nhn v sc khe ca i tng khm sc khe nh sau:
1. Khe mnh

Mc bnh

tn bnh: _____________________________

_______________________________________________________________________
____
2. t sc khe loi: _______________________
3. Hin ti /khng sc khe hc tp, lm vic cho ngnh ngh, cng vic (Ghi c
th nu c), hng gii quyt (nu c)
_______________________________________________________________________
____
_______________________________________________________________________
____

_______________________________________________________________________
____
_______________________________________________________________________
____
Ngy khm sc khe (ngy/thng/nm):.../ ..../.....
Ngy ht hn ca giy chng nhn sc khe (ngy/thng/nm):..../..../......
NGI K GIY CHNG NHN SC KHE
(Chc danh, k tn, ng du v ghi r h tn)

PH LC S 3
S KHM SC KHE NH K
(Ban hnh km theo Thng t s 13/2007/TT-BYT ngy 21/11/2007 ca B trng B Y
t)

nh mu

CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
*******

(4 x 6cm)

S KHM SC KHE NH K
1. H v tn (vit ch in hoa):.........................................................................................
2. Gii:
Nam

Sinh ngy: . Thng .. nm

3. S CMND hoc h chiu: ..cp ngy/../.. ti

4. H khu thng tr:..................................................................................................

5. Ch hin ti:

.....................................................................................................

6. i tng: Hc sinh, sinh vin

Ngi lao ng

7. Ngnh, ngh hin ang c o to/lm vic: ...........................................................

8. Tn n v ang theo hc/lm vic:.............................................................................
9. a ch n v ang theo hc/lm vic: .......................................................................
10. Ngy bt u vo hc/lm vic ti n v hin nay: .././
11. Ngh, cng vic trc y (lit k cc cng vic lm trong 10 nm gn y, tnh t
thi im gn nht):
(1) ..............................................................................................................................
thi gian lm vic thng nm t/../. n ../../
..
(2) ..............................................................................................................................
thi gian lm vic thng nm t/../. n ../../
..
12. Tin s gia nh: ....................................................................................................
13. Tin s bn thn:
Tn bnh
1.
2.
3.

Pht hin nm

Bnh ngh nghip:

1.
2.
3.

Pht hin nm

Ngy .. thng .. nm .
Ngi lao ng xc nhn

Ngi lp s KSK nh k

(K, ghi r h tn)

(K, ghi r h tn)

B Y T
S Y t/ Y t ngnh:

..

CNG HA X HI CH NGHA VIT

NAM
c lp T do Hnh phc
******

n v:

KHM SC KHE NH K
(Hc sinh, sinh vin

ngi lao ng

H v tn i tng KSK nh k: ____________________ ngy KSK ____ /____

/______
I. KHM TH LC
ln/pht
p:

Chiu cao:_______________ cm

Mch:_________

Cn nng:_____________________________ kg
mmHg
Vng ngc trung bnh:______ cm
Ch s BMI:

_____

Huyt

Nhit :__________ 0C
Nhp th: _______

ln/pht
Phn loi sc khe: __________ H tn bc s khm:

________ k tn:__

II. KHM LM SNG

1. Tun
hon:________________________________________________________________
_______________________________________________________________________
____

Phn loi sc khe: ________________ H tn bc s khm:_____________ k

tn:____
2. H
hp:__________________________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
3. Tiu
ha:_________________________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
4. Thn Tit niu sinh
dc:__________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
5. Thn
kinh:________________________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
6. Tm
thn:________________________________________________________________
_______________________________________________________________________
____

Phn loi sc khe: ________________ H tn bc s khm:_____________ k

tn:____
7. H vn
ng:______________________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
8. Ni
tit:__________________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
9.Da
liu:___________________________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
10. Sn ph
khoa:____________________________________________________________
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
11. Mt

Th thc: Khng knh: Mt phi: _______ Mt tri: ______________________

C knh

Mt phi: _____ Mt tri:______________________

Cc bnh v
mt:____________________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
12. Tai mi hng:
Tai tri:

ni thng:________ m;

Tai phi:

ni thng:________ m;

ni thm: _________________ m
ni thm: _________________ m

Bnh v tai mi
hng:_________________________________________________________
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
13. Rng Hm Mt:
_______________________________________________________________________
____
_______________________________________________________________________
____
Phn loi sc khe: ________________ H tn bc s khm:_____________ k
tn:____
III. KHM CN LM SNG
1. Xt nghim mu
- Cng thc mu: S lng HC: ____________ Bch cu: _________ Tiu
cu_________

- ng mu
_______________________________________________________________
- Khc (nu c)
______________________________________________________________
2. Xt nghim nc tiu:
- ng: _______________________________ Protein: __________________
- Khc (nu c) ............................................................................................................
3. Chn on hnh nh
- X quang tim phi: 1 Bnh thng

2 Khng bnh thng , ghi c th:

...................................................................................................................................
- Khc (nu c) ............................................................................................................
H tn ngi ghi kt qu cn lm sng: _____________________ K
tn: .......................
IV. KT LUN
Da vo nhng li khai ca i tng khm sc khe, kt qu khm lm sng v cn lm
sng trn y, ti xc nhn v sc khe ca i tng KSK nh k nh sau:
1. Khe mnh

Mc bnh

tn bnh: ...................................................

...................................................................................................................................
2. t sc khe loi: _______________________
3. Hin ti /khng sc khe hc tp/lm vic cho ngnh ngh, cng vic (Ghi c th
nu c), hng gii quyt (nu c)
_______________________________________________________________________
____
_______________________________________________________________________
____
_______________________________________________________________________
____

4. Hng gii quyt (ch nh iu tr, phc hi chc nng, khm chuyn khoa, khm
bnh ngh nghip, chuyn ngnh, ngh, cng vic khc ph hp vi sc khe hin ti
(nu c):
_______________________________________________________________________
____
Ngy khm sc khe (ngy/thng/nm): ..../..../...
TH TRNG C QUAN KHM SC KHE
(Chc danh, k tn, ng du v ghi r h tn)