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HEALTH DEPARTMENT OF BAC GIANG REHABILITATION HOSPITAL No.: | SOCIALIST REPUBLIC OF VIETNAM Independence-Freedom-Happiness |
Full name:
Sex: Age:
ID Card No./Passport No.:
Issued on:
In:
Current address:
Reason for examination:
DISEASE PREHISTORY OF OBJECT FOR EXAMINATION
- Disease prehistory of family:
Anyone in your family has one of following diseases: contagious disease, heart disease, diabetesmellitus, tuberculosis, bronchus asthma, cancer, epilepsy, mental disorder, other…..?
- a] No R b] Yes £ If answer the above question “Yes”, specify the name of diseases: ……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
- Disease prehistory of object
Do you have one of following diseases: contagious disease, heart disease, diabetesmellitus, tuberculosis, bronchus asthma, cancer, epilepsy, mental disorder, other…..?
- a] No R b] Yes £ If answer the above question “Yes”, specify the name of diseases:
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
- Other questions [if any]:
- Are you treating any disease? If answer this question “Yes”, list all types of drugs and dosages:
No
- Prehistory of pregnancy [for female]: No
……………………………………………………………………………………………………….
I commit that all above information are true and correct with my knowledge. | Bac Giang, December 24th 2015 Proposer [Signed] |
- PHYSICAL STRENGTH EXAMINATION
Height: 167 cm Weight: 57 kg BMI index: 20
Pulse: 80 times /minute Blood pressure: 110/70 mmHg
Health classification: Type I
- CLINICAL EXAMINATION
Content of examination | Full name of doctor |
1. Internal medicine: | |
a] Circulation: Normal Health classification: | [Signed] |
b] Respiration: Normal Health classification: I | [Signed] |
c] Digestion: Normal Health classification: I | [Signed] |
d] Kidney – Urinary – Genitals: Normal Health classification: I | [Signed] |
d] Muscle- knucklebone: Normal Health classification: I | [Signed] |
e] Nervous system: Normal Health classification: I | [Signed] |
g] Mental diseases: Normal Health classification: I | [Signed] |
2. Surgical medicine: Normal Health classification: | [Signed] |
4. Obstetrics and Gynecology: The vulva, vagina are normal Health classification: | [Signed] |
5. Eye Health classification: – Vision: Without glasses: Right eye: 5/10 Left eye: 5/10 With glasses: Right eye: 10/10 Left eye: 10/10 – Eye diseases [if any]: Short – sighted Health classification: II | [Signed] |
6. Ear – Nose – Throat a] Result of examination: Left ear: Normal speaking: 5 m Whisper: 0.5 m Right ear: Normal speaking: 5 m Whisper: 0.5 m b] Ear – nose – throat diseases [if any]: normal – Health classification: I | [Signed] |
7. Odonto – Stomatology: a] Result of examination: + Upper jaw: Normal + Lower jaw: Normal b] Dentomaxillofacial diseases [if any]: Health classification: I | [Signed] |
8. Dermatosis and venereal diseases: Normal Health classification: I | [Signed] |
- SUBCLINICAL EXAMINATION
Content of examination | Full name of doctor |
1. Blood test: a] Blood formula: Erythrocyte quantity: 4.3 T/L Leukocyte quantity: 6.4 G/L Thrombocyte quantity: 290 G/L b] Blood biochemistry: Blood glucose: 4,9 mmol/l Urea: 5,5 mmol/l Creatinine: 65 mmol/l ASAT [GOT]: 20U/L ALAT [GPT]: 28U/L c] Others [if any]:. Anti HIV [-], MbsAg [-], Anti HCV [-] | [Signed] Nguyen Thi Thuy |
2. Urine test: a] Glucose: Negative b] Protein: Negative c] Others [if any]:………………………………………………………………………. 3. Image diagnose: Heart: Normal Lung: Normal | [Signed] Nguyen Thi Thuy [Signed] |
- CONCLUSION
- Health classification: I
- Other diseases [if any]: Short – sighted
Date…month…year Concluded by [Signed and sealed] VICE DIRECTOR |
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