‫ﺷﻬﮭﺎﺩدﺓة ﻁطّﺒﻴﯿّﺔ ﺳﺎﺑﻘﺔ ﻟﻠﺰّﻭوﺍاﺝج‬

‫ﺇإﻧّﻲ ﺍاﻟﻤﻤﻀﻲ ﺃأﺳﻔﻠﻪﮫ‪....................................................................................................................................،٬‬‬

‫ﺍاﻻﺳﻢ ﻭو ﺍاﻟﻠﻘﺐ ‪............................................................................................................................................‬‬
‫ﺩدﻛﺘﻮﺭر ﻓﻲ ﺍاﻟﻄﺐ‪ ،٬‬ﺍاﻻﺧﺘﺼﺎﺹص ‪...................................................................................................................‬‬
‫ﺭرﻗﻢ ﺍاﻟﺘﺴﺠﻴﯿﻞ ﺑﻤﺠﻠﺲ ﻋﻤﺎﺩدﺓة ﺍاﻷﻁطﺒّﺎء ‪........................................................‬‬
‫ﺍاﻟﻤﺒﺎﺷﺮ ﺏب‪.............................................................................................................................................‬‬
‫ﺍاﻟﻌﻨﻮﺍاﻥن ﺍاﻟﻌﺪﺩد ‪ ........‬ﻧﻬﮭﺞ ﺷﺎﺭرﻉع ‪.............................................................................................................‬‬
‫ﺃأﺷﻬﮭﺪ ﺑﺄﻧّﻲ ﻗﻤﺖ ﻟﻐﺎﻳﯾﺔ ﺍاﻟﺰّﻭوﺍاﺝج ﺑﻔﺤﺺ ﺍاﻟﺴّﻴﯿّﺪ )ﺓة( ‪............................................................................................ ..‬‬
‫‪ .............................‬ﺏب ‪...................................................................................................‬‬ ‫ﺍاﻟﻤﻮﻟﻮﺩد)ﺓة( ﻓﻲ‬
‫ﺍاﻟﻘﺎﻁطﻨـ)ﺓة( ﺏب ‪.......................................................................................................................................‬‬
‫ﺑﻄﺎﻗﺔ ﺍاﻟﺘّﻌﺮﻳﯾﻒ ﺍاﻟﻮﻁطﻨﻴﯿّﺔ ﻋﺪﺩد‪ ...............................................‬ﻣﺴﻠّﻤﺔ ﺏب ‪ ...................................‬ﻓﻲ‪....................‬‬

‫ﺣﺮّﺭرﺕت ﻫﮬﮪھﺬﻩه ﺍاﻟﺸّﻬﮭﺎﺩدﺓة ﺑﻌﺪ ﺇإﺟﺮﺍاء ﺍاﺳﺘﺠﻮﺍاﺏب ﻣﺪﻗّﻖ ﻭو ﻓﺤﺺ ﺳﺮﻳﯾﺮﻱيّ ﻛﺎﻣﻞ ﻭو ﺑﻌﺪ ﺍاﻁطّﻼﻋﻲ ﻋﻠﻰ ﻧﺘﺎﺋﺞ ﺍاﻟﻔﺤﻮﺹص ﺍاﻟﺘّﻜﻤﻴﯿﻠﻴﯿّﺔ ﺍاﻟﺘّﺎﻟﻴﯿﺔ ‪:‬‬
‫▢ ﻓﺼﻴﯿﻠﺔ ﺍاﻟﺪّﻡم ▢ ﺍاﻟﺘﻬﮭﺎﺏب ﺍاﻟﻜﺒﺪ ﺍاﻟﻔﻴﯿﺮﻭوﺳﻲ ﺻﻨﻒ ﺏب ▢ ﻭو ﺻﻨﻒ ﺝج ﺻﻮﺭرﺓة ﺑﺎﻷﺷﻌّﺔ ﺍاﻟﺴّﻴﯿﻨﻴﯿّﺔ ﻟﻠﺼّﺪﺭر ▢ ﻓﺤﻮﺹص ﺃأﺧﺮﻯى‬

‫ﻭو ﺃأﺻﺮﺡح ﻋﻼﻭوﺓة ﻋﻠﻰ ﺫذﻟﻚ‬

‫ﺃأﻧّﻲ ﺃأﻋﻠﻤﺖ ﺍاﻟﻤﻌﻨﻲّ )ﺓة( ﺑﺎﻷﻣﺮ ﺑﻨﺘﺎﺋﺞ ﺍاﻟﻔﺤﻮﺹص ﺍاﻟ ﺴّﺮﻳﯾﺮﻳﯾّﺔ ﻭوﺍاﻟﺘّﻜﻤﻴﯿﻠ ﻴﯿّﺔ ﻭو ﺑﻤﺎ ﻣﻦ ﺷﺄﻧﻪﮫ ﻭوﻗﺎﻳﯾﺘﻪﮫ )ﻫﮬﮪھﺎ( ﻭو ﻗﺮﻳﯾﻨﻪﮫ )ﻫﮬﮪھﺎ( ﻭو ﺃأﺑﻨﺎﺅؤﻫﮬﮪھﻤﺎ‬ ‫–‬

‫ﻣﻦ ﺍاﻷﻣﺮﺍاﺽض ﺍاﻟﺴّﺎﺭرﻳﯾﺔ ﻭوﺍاﻟﻮﺭرﺍاﺛﻴﯿّﺔ‬

‫ﻟﻔﺖّ ﻧﻈﺮ ﺍاﻟﺰّﻭوﺟﺔ ﺇإﻟﻰ ﺧﻄﺮ ﺍاﻹﺻﺎﺑﺔ ﺑﻤﺮﺽض ﺍاﻟﺤﻤﻴﯿﺮﺍاء ﺃأﺛﻨﺎء ﺍاﻟﺤﻤﻞ ﻭو ﺃأﻋﻠﻤﺘﻬﮭﺎ ﺑﻮﺟﻮﺩد ﺗﻠﻘﻴﯿﺢ ﻟﻠﺤﻤﺎﻳﯾﺔ ﻣﻨﻪﮫ‬ ‫–‬

‫ﺃأﻛّﺪﺕت ﻋﻠﻰ ﻋﻮﺍاﻣﻞ ﺍاﻟﺨﻄﺮ ﺍاﻟﻤﻬﮭﻴﯿﺌﺔ ﻟﺒﻌﺾ ﺍاﻷﻣﺮﺍاﺽض )ﻣﺮﺽض ﺍاﻟﺴﻜﺮﻱي‪ ،٬‬ﺍاﺭرﺗﻔﺎﻉع ﺿﻐﻂ ﺍاﻟﺪﻡم ﺇإﻟﺦ‪-(...‬‬ ‫–‬

‫ﻧﺼﺤﺖ ﺍاﻟﻤﻌﻨﻲ)ﺓة( ﺑﺎﻷﻣﺮ ﺑﺈﺟﺮﺍاء ﺗﻠﻘﻴﯿﺢ ﺿﺪ ﺍاﻟﺘﻬﮭﺎﺏب ﺍاﻟﻜﺒﺪ ﺍاﻟﻔﻴﯿﺮﻭوﺳﻲ ﺻﻨﻒ ﺏب‬ ‫–‬

‫ﻗﺪّﻣﺖ ﻧﺼﺎﺋﺢ ﺗﺘﻌ ﻠّﻖ ﺑﺎﻟﻌﻮﺍاﻣﻞ ﺍاﻟﻮﺭرﺍاﺛ ﻴﯿّﺔ ﻭو ﺍاﻟﻤﺮﺗﺒﻄﺔ ﺑﺎﻟﻘﺮﺍاﺑﺔ ﺑﻴﯿﻦ ﺍاﻟﺰّﻭوﺟﻴﯿﻦ ﻭو ﻧﺼﺎﺋﺢ ﺗﺘﻌ ﻠّﻖ ﺑﻄﺮﻕق ﺗﻨﻈﻴﯿﻢ ﺍاﻟﻮﻻﺩدﺍاﺕت ﻭو ﺃأﻛّﺪﺕت‬ ‫–‬

‫ﻋﻠﻰ ﺿﺮﻭوﺭرﺓة ﻣﺮﺍاﻗﺒﺔ ﺍاﻟﺤﻤﻞ‪.‬‬

‫ﺳﻠّﻤﺖ ﻫﮬﮪھﺬﻩه ﺍاﻟﺸّﻬﮭﺎﺩدﺓة ﻟﻠﻤﻌﻨﻲّ)ﺓة( ﺑﺎﻷﻣﺮ ﻟﻺﺩدﻻء ﺑﻬﮭﺎ ﻟﺪﻯى ﻣﻦ ﻟﻪﮫ ﺍاﻟﻨّﻈﺮ‬

‫ﺣﺮّﺭر ﺏب …‪ .................‬ﻓﻲ ‪.....................‬‬

‫‪ : "$#!%‬ﻳﯾﻌﺎﻗﺐ ﺑﺎﻟﺴّﺠﻦ ﻟﻤﺪّﺓة ﺗﺘﺮﺍاﻭوﺡح ﺑﻴﯿﻦ ﺳﻨﺔ ﻭوﺛﻼﺙث ﺳﻨﻮﺍاﺕت ﻛﻞّ ﺷﺨﺺ ﻳﯾﻌﻠﻢ ﺃأﻧّﻪﮫ ﻣﺼﺎﺏب ﺑﻤﺮﺽض ﺳﺎﺭر ﻭو ﻳﯾﺴﻌﻰ ﻋﻤﺪﺍا ﻣﻦ ﺧﻼﻝل ﺳﻠﻮﻛﻪﮫ ﺇإﻟﻰ ﻧﻘﻠﻪﮫ ﺇإﻟﻰ ﺃأﺷﺨﺎﺹص ﺁآﺧﺮﻳﯾﻦ‬
‫)ﺍاﻟﻘﺎﻧﻮﻥن ﻋﺪﺩد ‪ 71‬ﻟﺴﻨﺔ ‪ 1992‬ﺍاﻟﻤﺆﺭرّﺥخ ﻓﻲ ‪ 27‬ﺟﻮﻳﯾﻠﻴﯿﺔ ‪ 1992‬ﺍاﻟﻤﺘﻌﻠّﻖ ﺑﺎﻷﻣﺮﺍاﺽض ﺍاﻟﺴّﺎﺭرﻳﯾﺔ ‪ :‬ﺍاﻟﻔﺼﻼﻥن ‪ 11‬ﻭو ‪(18‬‬