Phiu Chn on Ni Khoa

Ting Vit

Hy nh du vo ni c triu chng b bnh

Nm

Nam

H v tn

Ngy sinh

Nm

thng

thng ngy
N

ngy

in thoi

a ch

C bo him y - t khng?

C Khng

Ngn ng

Quc tch

Ch no trong c th b au vy?

au c

B ho

Ni ban

Hi hp

Hi th b ngt

Chng mt

Kh th

au bng

au bao t (d dy)

Huyt p cao

B t rn

Thy kht nc

Gim cn

Cm thy bng b chng

i ma

Mun i

Tiu chy

Mi mt

D mt

Triu chng khc

B st(

au ngc
B ph

Nhc u

Khng mun n

i tiu ra mu

B t khi no?

Nm

thng

ngy

c ln no b d ng do dc phm (thuc) hoc do thc phm khng?

C Dc phm Thc phm Ngoi ra Khng

Hin nay c phi ung thuc hng ngy khng?

C

Nu hin gi c em theo, xin hy cho xem. Khng

Hin ang mang thai, hoc c triu chng l c thai khng?

C thng Khng

Bn c ang cho con b khng?

C Khng

Trc y, c tng mc chng bnh no ghi bn phi khng?

Bnh ng rut v bao t

Bnh gan

Bnh thn

Bnh Lao

Huyt p cao

Bnh AIDS(SIDA) Bnh bu c

Bnh tiu ng

Bnh tim
Bnh Suyn

bnh giang mai

Bnh khc

Hin ti bn c bnh g ang phi iu tr khng?

c b m (gii phu) ln no cha?

C Khng
C Khng

C b truyn mu ln no cha?

C Khng

T gi v sau, bn c th t dn phin dch n c khng?

C Khng

http://www.kifjp.org/medical

NPO

2014.1