Mu 27

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)
1

S Y T NG THP
....................

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

S: .. /GKSK-2...................

GIY KHM SC KHE

nh
(4 x 6cm)

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 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)
1
2

Tn ca c s khm sc khe
Ch vit tt tn c s khm sc khe

Mu 27
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

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 khm

H tn, ch k
ca Bc s

1. 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: ............................................................................................... ...........................
2

Mu 27
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

H tn, ch k
ca Bc s

Ni dung khm
5. Tai-Mi-Hng
- Kt qu khm thnh lc:
Tai tri:

Ni thng:.................. m;

Tai phi: Ni thng:.................. m;

Ni thm:......................m
Ni thm:.....................m ...........................

- Cc bnh v tai mi 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 khm

H tn, ch k
ca Bc s

1. 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) Protein: ........................................................................................
c) Khc (nu c): ............................................................................

...............................
3

Mu 27
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

Ni dung khm

H tn, ch k
ca Bc s

3. Chn on hnh nh:

..............................................................................................................
.............................................................................................................. ...............................
IV. KT LUN
1. Phn loi sc khe: 3.......................................................................................
2. Cc bnh, tt (nu c):4...................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
ngy thng nm.................
NGI KT LUN
(K, ghi r h, tn v ng du)

Phn loi sc khe theo loi I hoc II hoc III hoc IV hoc V 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
4
Ghi r cc bnh, tt, phng n iu tr, phc hi chc nng hoc gii thiu khm chuyn khoa khm bnh, cha
bnh