Bài viết HEALTH CERTIFICATE – Giấy khám sức khỏe
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HEALTH DEPARTMENT OF BAC GIANG REHABILITATION HOSPITAL No.: | SOCIALIST REPUBLIC OF VIETNAM Independence-Freedom-Happiness |
HEALTH CERTIFICATE
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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