CONG HOA XA 11011 CHUIIA VlICT NAM DOe lap - Tv do - Ranh phtie

GIAY KHAM SIYC KHOE

-19 va ten (chit in hoa)• NG3.1.1.EN 1H.1 : Nam 0 Nu Tu6i-

36 CMND hoacaHO chieu:.d-9.1.2..5.533 ,./>lgay cap- 0.(A42... Tai • CONG /AN "T)-1k):A -1-4jZhi 1-11.tC Theo hien_tai• aLCA,..G.0 "TU.' 111.61fri

"ft Ilik`.% HuL kham sirc khoe• .CA

020 :Ak., (OZ:a

0003 ; I ENH CUA £061 TUTING KHAM SUC KHOE evu 9UAN Y

1. , 4., I I.

CO ai I .4.171.5V ' ong (ba) mac mot trong cac benh: Truyen nhiem, tim mach, dai Milo dtremg, lao, hen phe quart, ung thu, dOng kinh, roi loan tam than, berth khac:

a) Khong 0; b) Co 0 Neu "c6", de nghj ghi et) the benh•

2. Tien sti. bin than: • Ong (ba) daidang mac benh, tinh trang benh nao sau day kitting: Benh truyen nhiem, tim mach,

dai thaoduang, lao, hen phi. quart, ung thu, deng kinh, r6i loan tam than, benh khac: a”theng 0; b)C6 0

,.Neu "c6", de nghj ghi cu the benir

3. Ciu hoi khic (ntu cif): a) Ong (ba) c6 dang diet' tri benh gi kitting? Neu c6, xin hay lift kC cac thy6c dang dung va

lieu luong:

b)Tie'n sir thai san (D6i v6i phy n&):

Tot xin cam doan nhang diet] khai tthn day hoan toan dUng vei sv that then w hieu biet cila toi.

. nga nam .1)1dg

Ngtroi de nghj kham sin khoc (K)-; va ghi re hp ten)

4 awn cjaa.7, 0a111---•

at

Iir e):Fren Ma: •

Ca-xtron-khdp

Iiikeilie'frxt., Phan lo?i•

1C4,1

twat'

g ten, chic ky Qua Bac si N6i dung khant

r

d)l-han-tiat &tn

Phan Joni.

Mr

Eaciurryht Katt cji Phan loai•

e) Than kinh:

Phan loai• 7 g) Tim than: CIA

1. N6i kites a) Than holm:

Phan loai•

b) H6 Ilp:

Phan lo4i• Brat: gaivi !ii2C

BM. Si, /4' %fp Phan loci.

ti. 101AM THE L.ACC Chia! cao:....4.5.0....cm; Can flaw C kg; chi so BM]•

mohd lin/phin; Huy& ....mmHg

Phan !nal the hit. C

H. KHAN LAM SANG

2. Ngopi khoa:

Phan loai.

3. Sin pity khoa:

•

Phan lopi•

4. Da liCu• 14

Phan Iopi•

5. Mit:

- Kham thj lye:Kiting kinh: Mit phai• -At Mit trai• at/

C6 kinh: Mit phat• / Mit hid-

- Cac birth vE mit (nEu co).

Phan lopi•

6. Tai-MOI-H9ng:

- Kit qua kham thinh Ivc:

Tai tnii: Noi thirsting.

ICm;

Nat thim m Tai Oat: N6i thuimg• m; Not thim

- Cac binh vE tannin hong (nau c6). I

Phan loots

7. Ring-Ham-M4t:

- Kit qua kham: + Ham tren•

Ham du6i•

- Cac b4nh vi Ring-Ham-Mat (niu co)'

B8. UCLA ird "Aony

esaittir

BS. eirryin.6ilmit

asvatifriesfr tat

Phan lopi•

/ P2

41

I. Xet nghiem mitt:

a) tong thirc maw S6 lurrng tic

se) luvng BC• 6 - 9

SO luyng IC- iq K

b) Sinh h6a tnitu: Outing maw it• e" ALM (4•

Ure - s-3 • 3./40.4111. Crcatinin- AO SGOT- ....... SGPT-

Khac (nett c6)•

flu ten, chit 14 ctia Bac at

Noi dung khan]

b) Protein-

c) Khac (nEu co).

2. Xet nghtem nut tieu: a) Outing

Ifinhlinkthn phei trong gidi hgn binh.thilimg

CNKH.t siNweitm

latintirsay

3. Chan Bonn hInh inh:

Khac (nEta co)

con MACH NW ow

thang..t.nam 20 I fi KET LU*Isl

BS.C111 ;sin ;Loft

HI. KIIAM CAN LAM SANG

IV. )(ET LU/NN ( :cc

2. Cac benh, Cal (nett c6)•

Ket Iujn

D41 It. kixie.4afft.:):1Y

I. Phan loui sat khoe• t

%IA( CRY MIAS' Slit KIME 1MM; CII0 IR Ti :01 TRO I. I" Arm: ..:ec Ming it; .1 77 4;1 T niv; ,16 _.''' ., 110 Iron Itt; .

I DAIGIOA • :-NGUYIK VAN rt

THIN HUE CONG BOA XA HQI CHU NCHIA VitT NAM DOe ICtp - Tv do - Ranh phtic

GIAY ICHAM SUC KHOE

Ho va ten (chit. in boa)... _EWAN .. .)<DAN AM Gieri : Nam 0 Na 121 Tuoi: .27' S6 CMND hoac 110 chieu• 43.13:415.13 Ngity cap: (lg./Q.206.3 TaiC . Ch6 ahien ai • -714 t

am sire khoe: Sd neft sis -..y

MN Y,

; 1"4 Y

• /B LtNH CUA DOI TUVNG KHAM StiC KIVA

I. Tie CO ai trong gia Binh Ong (A) mac mot trong cac benh: Truyen nhiem, tim mach, dai th.ao throng,

lao, hen phe quan, ung Chu, dOng kinh, rti loan tam than, benh khac: a)Khong 0; b) CO 0 Neu "co", de nghi ghi cy the berth:

2. Tien sir ban than: Ong (bit) da/dang mac benh, tinh trang benh nao sau day khong: l3enh truy en nhiem. tim mach,

dai thaodutmg, lao, hen phe Ivan, ung thu, dOng kinh, r6i loan tam thin, benh khac: a) KhOng 0; b) C6 0 Neu "co", de nghi ghi cy the benh:

3. Cau hm kink (lieu co): a) Ong (ba) c6 dang dieu trj benh gi kitting? Neu co, xin hay liet ke cac thu6c dang dung va lieu luqng:

.b)Tin sir thai San (ID& phy n&):

Tel xin cam doan nh&ng (lieu kitai tren day hoar) wan thine vol sv that theo s1r bleu bier cect tel.

t , a .. ngay..23. t ha n g.3.... narn .2C1i5

NgtrOi do nghi klisim sot khoe (Kt"; va ghi r0 ho ti-ni

N6i dung khan) Ho ten, chir kj, ctia

Bic si

lrattIn UAW

Phan 104i•

b) H6 hap: 6

Phan luai•

4 Tien he a:

Phan ;.;.?4; •

d) Titan-tic( ni6u: far.

Phan loai•

8) Co.-xtrang-khirp

A

Hs.cm.„tryin fiat Phan ioai•

e) Than kinh:

BsC

E. ICHA.N.I Ti'irtv 1 1,1(- Chit.:o cao:....4-51.1....cm; C:an nang. •LZ— kg; Chi .s6 BMI• .,

4,‘ . • • r • • • Miftch. L2: raniphat; Huye't ap:Ate / •Av .. mmHg

t •

Phan 10{1i the lye.

- II. KHAN4 LAM SANG

I. Nqi khoa a) Tulin huhu:

YY

Phan roar

g) Tam than:

Phan 1(4 -

Ngcroi kittea: [%-

Phan loaf. 1

3. Sin On khoa:

•

Phan !oat.

4. Da ll'eu•

Phan loai•

5. Mit:

- Kham tin Itrc:KhOng kinh: mat phai: ,/te'lete)

CO kinh: Mit phai• r

Mit trai• AP V°

Mit triti•

- Cic benh ye mat (neu co).

Phan loai•

6. Tai-Miii-H9ng:

- Eat qui kham thinh 19c:

Tai trai: Not thrimg. m; Nei tham

Taiphai: Nat thuarng• m; blot thim

- Cac berth vtlai milt h9ng (neu co).

m (15

to

Phan loaf .

7. Rang-Ham-Mit:

- Ket qua kham: + Ham tren•

+ Ham dueri•

- Cac benh ye Rang-Ham-Mat (nett co). 14a

Phan loai• . BS. CK1 At,

jil KIIAM (iNN LAM SANG

Nil dung kham tin ten, ch& kS. ctia Bac si

I. Xei ngltiOn uniu:

a) Cong auk mau: SO lucing HC:..c.5.t)

SS luqng BC:...54

SO luy ng TC:..I.4

b) Sint* luia mau: Dubng maw

Um. C.10 ironti SGOT '{J).(t

Kluic (nett co)•

4L i y 710 i

4 A.C19 IL 1 9

,AC) .../K LL

44g inn

Creatinin•

SGPT C'121

I L.--

n 49 uad Y i 2

tl• li... , ...::.

2. Xe1 nghiOn nu& flea: a) Dudng•

b) PrOtein• ' IA ri.3.,i14.H

c) Khhc (n'eu co). -

• ChiPtettilkimi ,71

77-- 1# liiii 61, 'stem

3. Chin clown hinh anh: '

Huth tinh tint phi trong Khac (neu co) !. r idi Mtn. bin f rth a*: ,LY .

IV. Kt.T 1..11/01 1. Phfin Ioai sti-c khoe•

OcC.t.. 2. Clic b0h, It (nEu c6).

Kt loan: Do SliC kh6e lam ic .5t

...,252 -..,o• 9.

/to

CONNRLY .%23 ifridng.nnelm 20/(9 I -. TRACtimpfmitilio, en KET LUAN i! i.. CyuGUAN Y i

4 NGUIiiilliK .... _ 77

. ,, • , r

iv' • 'I. • t Ato„ •

.01•••..•

.*

•

',; \ \ .1 1.111,1 Hi. %I. 1! ;1* \ 1.1. int Of 1!../ ) I ! •:

Sir 17 t Dan "

CONG BOA XA HQI CHt1 NGHIA VI€T NAM HQc lOp - Ty- do - 1-13nh phut

•

GIAY MIAM SITC KHOE

Ho va ten (chitin hoa):::t101:11* 1H1 llantr Yt Gi6i : Nam ❑ Nit (21 S6 CMND hoac He chi& 49455.0,24.:)....Ngay Tai • Ca25...An. Cho a hi

LtSkham sec khoe• a

C0113

.k Lyko 150r; y :; MVigicc

1. is Co ai ong (ba)mac met trong cac benh: Truyen nhiem, tim mach, dai than dueng,

lao, hen phe quitn, ung thu, deng kinh, repi loan tam than, benh khac: a) Kheng 0; b) CO 0 Neu "co", de nghj ghi cu the benh•

2. Tien sir bin thin: Ong (ba) di/dang mac benh, tinh trang benh nao sau day kheng: BEM truyen nhiErn. tim mach,

dai Chao dtthng, lao, hen phE quint, ung thu, dOng kinh, r6i loan tam thin, bEnh khac: a) KhOng 0; b) CO 0 NFL "e6", dE nghj ghi co thE benh•

3. Can hei khac (nett co): a) Ong (ha) co dang dieu trj benh gi khong? Neu co, xin hay het ke cac thuoc dang dung vit

lieu Incing:

.b) Tien se thai san (DOi voi php ner):

Tel xin cam doan nh&ng dieu khai tit) day hoan wan thing vel sir that thco su hien biet cea tel.

Altti , ngay..23. nim 2O.1 Nguiri dE nghl kharn sirc khoe

(K.), vá ghi re) hp ten)

.71 mai 1 (_

-LOAN Cr 1 1\-)6

CNH CUA DOI TIKING KHAM Sit KHOE

Ph:1'n 1001• I

i. IC!..1 .11k1 I !nn: ..rtr . ''him 1...ar...(tt.3 cm; Can nang: -54 kg; Chi sj; liMI• Mach• (i 1-: hinthat; Huyat aria / 4te' ninlig

Phan Ina' ilia I9c:

H. KIJAM LAM SANG

7

Phan loai-

b) Ha hp:

Phan 14

c)*TiEu h6a:

• tit

Phan ion;: 111.

el ThAn kinh:

r Phan loai•

g) Tam than:

Phan lokli•

NO dung khan)

1. NOi khoa a) Than hoin:

cto Twos, otaa

7C1 illArta/' n 111: r t .17'

d)Thcin-ti& ni'u:

Phan loai•

d) Cu-xtromg-kh67)

Hy ten, cher ky cua Bac si

2. Nge3i khoa:

Phan looi•

3. San pho khoa:

Phan loai•

4. Da Niue

Phan loai•

5. Mit:

4 Bs. aryitt &ay

- Kham thi loc:KhOng kinh: Mat phai• Mat tilt.

CO kirrh: Mat phai:../Ite Mat trai: .. lite - Cac benh ve mit (nEu co).

Phan 'oat . e 6. Tai-Mii-Hong:

- Ket qua kham thinh

Tai trii: Noi thrang• m; Not thitn

phai: N6i thuCmg• m; Noi tham m VI")

- Cac benh ve tai mai hong (nEu c6).

Phan loai•

7. Rang-Him-Mit:

- Ket qua kham: + Him von.

+ Ham duoi•

- C ve Kiing-Ham-Mit (neu co)• f

Phan loai• BS.CKlaVritiAlto,

6\ 3"

CoNG TY TRACIINOIEMIdlli

* CUu 9uAll NGnINIUA

.y.).51heing.0,51Cren 202 J. KET LUAN

BS.CK.11.N!.?ivt;s1 Xthin

;

Neji dung khan! 1-112 tit!), eh& ky Chia Bac si

U:- ughiOn mau:

-a) Gong thirc man: Se) Inking HC• 10-

S6 lacing BC:...51.3..X.

S6 I ming TC• :II

b) Sinh 1145a mini: Duang maw

ure. E.1:5 11,01Ctil

SCOT. c)1,a11,9

Khac (ne'u co)•

s- AS'

/lc

kI9 An

If \

Creatinin.

SGPT.

\L 9 ii

kt

(

151

ailainiaouttigit.

19\191.'

tfniloirnicidardfity

2. Xet nghim tarot lieu: a) Du&ng•

b).Protein• '

c) KhacKhat: (neu co).

, ,

3. Chan doin hinh inh: '

Iiiiih iii ih tint phittrong Khac (nu co) gializqn buth tharng .

IV. KET LUAN 1. Phan lo?i sin khoe• • T

2. Cac bOti, Of (nett c6)• Coin 4L Kt litan• DA.Suc 66e lain vi4c

‘I Ci ;.!4 t Kifra pi-sc • 11:17..3 '01 IVISTI UI Tito ;! 2„;3,;7.;,, g. gut flu !tuna); het

C'QNG IIOA XA 1101 CHID NCHIA VItT NAM Elk lap - Tv do - Honh phtic

GIAY KHAN4 StrC KHOE

NO& EA P.44(4. ..Satl

Nir 0 21 Ngay cap. /1),./.4 /2015

-r.

Ci

I. TiEn

Co ai trong gia dinh Ong (ba) mac mot trong cac bEnh:Truyen nhiem, tim mach, dai thao throng, lao, hen phe quan, ung tpu, gong kinh, rSi loan tam thAn, bEnh khac:

a) Kh6ng b) Co 0 Neu "co", de nghl ghi ctr the bEnh•

2. TiEn sir ban than:

Ong (ba)dWdang mac benh, tinh trong bEnh nao sau day kheing: Benh truyen nhi&n. tim mach, dal thao duemg, lao, hen phe quan, ung thu, dOng kinh, rat loon tam than, bEnh khac:

a) Kheing b) CO 0 NEu "co", de nghi ghi co the benh•

3. flu hat khac (nEu co): a) Ong (ba) co Bang diEu tri bEnh gi kh6ng? NEu co, xin hay liet ke cac thuSc clang thing vi lieu lugng:

b) Tian sir thai san (D6i vol phy net):

T6i xin Cam doan nhang dieu khai nen day hoan town thing vei so that thee so. hien hietcua tei

ngay.23.. t ha ng..3... flan .200 Ngireci de nghi kharn sire khoe

(K1% va ghi ho ten)

Nio4 euil se)

H9 va ten Wilt in hoa)...... Gieri : Nam 0 SS CMND hoac HO chieu Toi• 11,..2 7. — Chi; o hiEn tai' 79‘. .-.1 7.9,.-„

14.9 T I' '42 Larn . Si.7 .S4 ..niii sac khoe•

*iiitniA '.'7 1 .

NH CUA DOl TUVNG KHAM SUC KHOE

• 492.0.51/12. +LS

Ni( dung khan)

1. NOi khoa a) Titan hoary

Phan loui• n

1

b) Ho hap:

Phan loa;• .1.

e) Tien hos:

()A

Phan kuti

d)Thjn-tiel natty

Ho ten, chic Igt eau Bac a

Maar Itt.:„

E. !CiAM .. ,.. ....;t ...,.... A • 'in;

Mach .. . . Sk.' Ian/phut: Huyet arr ,AAQ ,' EC mmHg

Philo Ioai (he hit•

KnAm LAM SANG

can nfing rV kg: (- hi so EsMI:.

Phan Ioai' BScru ger

Co•-xtro-ng-kherp

V 1j

Phan 'ffiai B.5.(111,,liteyea urn( e•

ei Than kinh: •

Phan logi•

g) Tarn than:

Phan logi•

in; Noi tham......r to •

2. ligoai khoa:

Phan loai•

3. San ply khoa:

•

Phan loai•

4. I)a

agau.Aigilajtat:

Phan loai• •••••••• BS. "flirt

5. Mit:

- Kliam thi Itre:KhOng kinh: Mit .. .... Mit trait...

CO kink. Mit phai - Mit trai•

- C5c benh ve mat (neu co).

0 •

ss,aultdia#fir :aids Phan loai•

6. Tai-Mui-Hong:

- Ket qua kham thinh lye:

Tai trai: Nei thuOng•

Tgphai: Nal thSng m; Noi thinn.

- Cic benh yeti null hog (neu c(5).•

n Phan foal.

7. Ring-Ham-M4t:

- Ket qua kham: + Ham tren•

I I lam duOi•

- Cite henh ve Rang-Ham-Mat (neu co)' Iliad

Phan loai• Bs. caiti .0491

NO dung khim H9 tin, chi: kj, co::

Bic ri

sciagoiassaiss

I. Xet nglqin mau:

8) C.:Ong thirc min: S6 Wong HC. 14 e ..1 l - \L

S6 luvng BC 311..A.. A 9 LL

S6 hrog TC. 44.1 x. AC.3.).L.

b) Sinh h6a man: Duimg maw Ili pa/ id

Ore. LI Creatinin. AC kii4

SGPT 3.04

Khic (neu c6).

2. XCt nghitm wet tiau: a) DuOng.

13) PrOtein.

c) Khac (neu c6) - AM TIN!

3. Chain doin hinh anh:

scot. .mill

Binh ink term phe t frong Khac (nett c6) gillingstbinh.dureng_.

DU Ric klyie lam v C

thdngnium 20/CT 1 KET LUittri

*rriltrA cS.CK IL N,quyin Kith: Li

‘1. (110 1cci.41)111 oi fu.,l

!il. KliArket CNN LAM SANG

IV. KET LU4N 1. Phfin Iog1i sac khan.

2. Cic bnh, (ntu c6).

KICt lufin.

\ 1 I

GIAY KHAM SITC KHOE

a Hq ve ten (cher' in hoa)....N1611.Y.EN..7aff....N.W...N<A1 Giai : Nam 1:1 Nag Tu6i. S6 CMND hoac HO chieu:....4,91.a.I.r./..6 Ngity cap. .4t)// z....es.tE Tai. Ce :11,z4„, kluen (le et hien tai• c . Ltd .Ci:an. at:

•

,-;r: V Otrn

Tst

OA DMA liGlaltiV MAN DO

COW; HOA XA HO CH tO NGHIA MT NAM DOe lap - Ttr do - Hanh phtie

LS, do k ham stk. lathe• acne. irk ..,-41r .Cetki

4111.11.111

.$ NH CiJA Dol TONG KHAM SUC KHOE to l •

I • Ti_taNclichz CO ai • : 1 fang (ba) mac mot trong cac benh: Truyen nh tem, tim mach, dai thao clueing,

lao, hen phe quan, , dOng kinh, r6i loan tam than, benh a) KhOng b) CO 0 Neu "c6", de nghi ghi cU the bent].

2. Tien sir bin than: Ong

(ba) dA/dang mac benh, tinh trang benh nao sau day kheing: Benh truyen nhiem. tim mach, dai Chao clueing, lao, hen phe quan, ung thu, Ong kinh, rat loan tarn thin, b'Oh khic: a) Khong b) CO 0

Neu "c6", de nghj ghi cu the bent'.

3. Cau hoi khac (nett c6):

a) Ong (ba) cO dang diet' trj benh gi khong? Neu c6, xin hay liet ke cac thuoc dang diing va lieu Mpg:

.b) Tien sit thai sin (D61 yeti phu n&):

T6i xin cam doan flitting dieu khai tren day hoar) loan dung ye' sv that theo sv Neu Net ctiet toi.

ngaz/. min .2,019 Ngtreri de nglij khim stir khoe

(Kfiva ghi ro hg ten)

N +Di (\IL, r•-to„

I. NAi khoa a) Titan hoin:

lig ten, chit Hie si Ni dung kharn

. K. i TI' Ak Chit' can:. . ...... cm; Can .......kg; Chi so rim!.

tvikicti• 4 ran/print; 1-lnyEt air , 31.-1 mmHg

•

Phim loci th& lue•

ICHAM LAM SANG

Phan 10.n:

b) Hñ hp:

I+)

Phan 14

r)Tieu Ma: L'S. el.,&•friggriecgiiin9

Ath

Phan

d I ThAn-tiet nk,u:

tgari ;UK/ icocui;Witq Phan loai:

d) Cor-xtromg-kherp 1/

/1

Phan ;co TI

c) ThAn kink: 71

Phan 1o4i*

g) Tam thfin:

7 • Phan Iekii• 4

I! ,

f 1/4,1111(

- Cac benh ve Rang-HiumMit (neu c6

Phan loal•

s.act9,147C,

Muni.

Phan loat•

3. Sin phi, khoa:

Phan loai•

4. Da lieu•

Phan loai•

5. Mit:

- Kham thi l‘rc:Khong kinh: Mit phai:...A.0 Mat trai• .... CO kinh: Milt phai- Mitt trai•

- Cac bfnh ve mat (neu c6).

Phan loai•

6. Tai-Miti-Hong:

- Kat qua khan thinh

Tai trai: Nei thutmg• .m; Nei thim m Tai phai: Noi Muting. m; Nal thirn. 5 m

ECK!! .,:fgayin. geese

- Cac benh ve tai mtii hong OIL c6).

Phan loai•

7. Rang-Him-M4t:

- Kat qua khan: + Ham tren•

+ Ham duOi•

Ascaceikirlia

1. X6( nghifm man:

1 H9 an, chic kj, ctia Bac si

•

NOi dung kham

a) COng thin mau: so lugng

S6 lucyng , i(n

Si; !using

b) Sinh hoa miu: Duirng maw 41.

Creatinin. 712- 04.l1,9111.( Ure:...

Sear di Son. 22: (

Kruk (neu c(5).

(

lat lus)n•

IV. KIST LUAN 1. Plan Ioai sat kh6e: ........................

2. CU tofnh, tilt (ntu co).

Khic (n6u co)

3. Chan (loan hiub all:

lignis ink tint phi) *mg hqn binkiktithvg

*kik( Oink. kh6e.iim vie&

tali *soh

Ii!. KII/C.M CAN LAM SANG

2. Xel nghifm ntrec ticu: a) Duong.

b) Protein•

c) KhAc (14u co)

4114:4alitilluing0 nam 702E1 ,NOtiol Kt!' LU AN

IS 71

khoe• id

A

; F •

PHONG KHAM DA KHOA CQNG HOA ILA ROI CHU NGHLTA VItT NAM

Y KHOA PHAP VIST DSc lap - Tv do - Minh phut

. GKSK - PKPV

GIANICEIAM stc KHOE

Ho vi ten (chfr in hoa):

(lA: Nam DB Ntt 0 Tubi:...Z2- s6 cks:ND hoc 140 chi& ..d3.1.a.135.1cap

Arc. 1- tetarr-77.1:441: n ligt Wk. J2,-4. f ha". Uv.. L.Lal

titk sir BtNH CiJA DOI TUQNG KHAM Sit ICHOE I. Tan sir gis dlnh:

CO ai trong gia Binh 8ng (bi) mic meg trong cic berth: truyin nhiirn, S mach, did thin dating, lao, hen phi quip, tmg thu, dung kink, roi loon tam thin, binh khic:

a) Khing Iii; b) C6 0; Neu "c6", dP nghj ghi cµ the ten bank:

2. TIM sir bin thin: Ong (bi) di/deng mic binh, dull trona With oho san diy khing: Bich truyin Maim, binh dm mach, thio throng, lao, hen ph6 qtuln, ung thu, ding kink reef kin

tam thin, Wok khic: a) IChing 0; b) C6 ❑

Neu "c6", di nghj ghi co thi tin binh:

an bei khic (nit co): a) Ong (hi) c6 dang diiu uj With gl khing? Neu c6, xin My Het kick thubc dang dung vi lieu limn:

b) Tien sir thai sin (D6i veri pho ne):

T8i xin cam doan nheng diiu khai tren day hoin loin &mg yen sv that theo stir hitt' hitt cua t8i.

Hui, ngity theing..3...rom20.1.5

Nguii di nghj khim sic Ichie (K, th ghi rt hp, ten)

nW1 THAN/14 Ni-/AN

I. KIIAM nit Ltrc - Chien cao: . cm; Can n4ng: .... 7J .. kg; Ch! s&BMI: . ...... _ Mach: ...

Huy& ap:—/IL.-- mmHg Phan loco thi hrc: .... • - ........ •

/CRAM LAM SANG

H9 ten, cher Icy ala Bic sy

........

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

vr•

••••• ...............................

Nt11 dung Mita 1. NOi khoa

a) *Nan hoary

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

phanloci :...............:.............. .................................... b) Hel : ............................................................................................................

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

ffiNfl TiltreNt Phan .. c)

Tido Ma: ............................................................. 7 ......................................... ......................................

ihor•Tautir..tia. ........................................................ it

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Phan......................... -L ..............................................

d) Tin-Titt nieu: ........................................................................................................

............................... Phan logi•

d) Co-xtrang-kheip ...................................................................................................... ...

........................................ •Binirrinnytio•

Phttnto...................... ......... .. ................................

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

c) "Wu) kink: ...............................................................................................................

BiAlil THWING Phanloai: ........ ......

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.......... g) than: ....................

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....................................... •BitIE.•litjaN6.1. .............................................................. Phan loa.i•

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2. Ngopi khoo .........................................................................................................

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fRANG.K

Phan loaf. :T. 3. Sin phy thoa: ,

Phan loaf

4. Mit:

- Kat qua khim thj Khong kinh: Mit phid: MEt Si: •

Cd kinh: Mit phai: Mit trail: --—. Cac benh ve milt (neu co): ....

***** ••••••••••••••••••••••• ****** •••••••••••• ***** •••••••••••••••

Phan !oak .....

.......

sase••••••••••••••••••••••••••••••••......... S. Tai-Mili-H9ng

- Ket qua kharn think Tai N6i thtrong• S m; 1461 tam: Tai phai: N6i m; - C.tic benh ve tai mdi king (n en co):......__

-• ......... •

.sitorrpttitina- Slt•lireilr:41•41fts

PNON

PHoNG

- Phan loaf:

6. Rang-Ham-Met

- Kat qua khan': + Ham tren:

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

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÷ Ham d treri : . . ... - Ctic henh ve Ran Mkt(neu c6)..

.........

See

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- Phan

7. Da lieu: ...........

. •

Phan

PRONG

m. KHAM CAN LAM SANG

NiO dung khim I - -

119 ten, clitt 14 - -efi38itc-sy-

{AM xtiNGHIEM , 44.• 0-...

1. Xit nghittu miu: 1- T1311197i „J.? 1

a) Cons thUc miu: S6 lucmg RC. 5.) --) i x eal I I. Y KHOA•Rei SO luting Bach ceu: ...9.)//..E y /OIL So Immg Tieu ciu• el.? a ts Zet IL

b) Sinh Ma miu: Ehrtmg mku: Ol

Ure.

ASAT (GOT). ALAI (GPT)- .... .

c) Kluic (nit c6).

610ifirtgig -- ‘7 .._..........erC

2. Xit nghifm nuoc

a) Dubng:

b) Protein.

c) Khic (Au co).

a ' •

4;

3. Chin darn blab Mb: —llintrinir tun phiitmUttinidet----- ...

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

-KhIc ( n&u c6)-

'ENDA --1-11414•ANK

6-14414.0441 4- 4

—

IV. KET LUAN

1. Hien lulu sec khor , Hitnialfist.kbOA.delim.vik

2. Cie binh, t#t (neu c6):

••••••••••••••••••••••••••••••••• ••••

Hue, thang.3.. flair 1.0.,9 GUM KET LUAN

,-0 • 2 . /+7, . !Ve*:: \• hp, ten vit dong dino

hkgcle PMAC`hlT

X C ‘'NG TY c5

‘ k I !ONG Cilcy ?Kim KHoi P,'Go

es= gaiA teig (60641