sO y TE TP. HO CHi MINH BENH VIEN DA KHOA VAN HANH eh HO SO KHAM SUC KHOE FORM OF HEALTH CHECK-UP’S DOCUMENT Ho va tén /rarmome..P Ai YEO FA Nam sinh Jem year ATE... Gi6i tint I6ondor fu QUSC tich Instone... OALAYY Di dong / Prone no:...0931 848. 634..... Email: Ten cong ty / none of company../ong..Dy.. TEL... NUEA.... BENH VIEN DA KHOA VAN HANH 781/B1-B3-B5 Lé Héng Phong (ND), Phuong 12, Quan 10 www.benhvienvanhanh.com Email: khamtheohenvanhanh@gmail.com Tel: (028) 62934797. CONG HOA XA HOI CHU NGHI, 2, HOM . AVIET vd re HOA VAN HANH gc lép -Ty do-Hanh phic VAM BeNHVIEN DAKEE’ SOGIALIST REPUBLIC OF VIET naty sbgtay IGKSK-2024 Indepondonco- Freedom Hopping GIAY KHAM SU'C KHOE CERTIFICATE OF HEALTH EXAMINATION (pong cho ngudi tir a0 18 tudi tréy In / For an individual with 18 years or older) ( Jay 06 thang 5 ném 2013 ctla BO trun, (Théng tw sd 14201 ey orurevt Ged Moy 6, 2013 oho nae? A) mvoay LARC. .LYEONG. TEAL, va tén (ch ASrne tere Nam sintsien yor 0, Gidilser: Naminge EE Nirona S6CMND nage Ho cid ocr rue a 6003 0 Aa cp nga [sat otssue: = ), ja cht hign tal tal VN/curen atessn non. ir eter Kham strc khde / Reason of health examination: .. s BENH CUA DOI TUQNG KHAM SUC KHOE DISEASE HISTORY OF INDIVIDUAL 4. Tidn sir AMIN LM nso: - Cé ai trong gia dinh éng (ba) mac met trong cae enh: truyén nhiém, tim mach, dai thdo duéng, tao, 1. ung thu, dong kinh, rdi loan tam than, bénh khac /tas any member a ae en este at Gerais bene cre payment Soe ooeroegeo a) Khénglo 1; b) CélyesO; Néu" 8 nghi ghi cy thé t&n bénh/ ye; tis oqured toca se Ong (ba) d/dang mac bénh, tinh trang bénh nao sau day khong: Bénh truyén nhiém, bénh tim mach, dai thao dudng, lao, hen phé quan, ung thu, dng kinh, réi loan tam than, bénh khdc / Have you ever got any esease, es following: Infectious iseese, heat disease, iabetas melitus, tuberculosis, bronchial astra, concer eplesy, mental dsordes, other disease: 7 a) Khéng/no HJ; b) Cé/yes 1; Néu “cd”, 48 nghi ghi cy thé tén bénh/ir-yes trename of esse. 3. Cau hoi khac (néu €6) / otter questions (any: a) Ong (ba) c6 dang diéu tri bénh gi khéng? Néu cé, xin hay liét ké cdc thuéc dang ding va lidu lvong (sorter please list drags and dose you are using Is required to clearly state b) Tidn si thai san (Bi véi phy nd) / iy en Toi xin cam doan nhiing didu khai HOMO. Nodyliy.»3...thanglnoin AA. .némies. oe trén day hoan toan dung voi sy that 6 festa ire nat the above tion is: y 6 ony a ert te "bande tsi (signature, ful name) fot eye ue {o44 ye J esica exaunarin i Hee TO om Cnn mae. 20 7 ore [3Br.u1&n / phit /ones Grae eee Ha el thd vc Paes clsaleaton oof, ABQ. ie LAM SANG / cumcnt [EXAMINATION Mi 1 KHAI Ngl dung khdm / Content of medica! examination ‘Ho tin, chivy | 8 bbe 7 Futnane NOt hoa! intemal medicine : . ‘puan oan / cardiovascular system: aoe : phan loai / cessfeaton b) HO dp / Respratory system: phan loal / cossteston ) Tu n6a / Deen sem phan loai / casteston g) Than- TiSt nigu / Urinary syst. phan loai / clssicaton:.. 4) Co - Xuong Khép / Mecano sen phan loai / clessifeation:.. alee e) Than inh / Neurological system: phan loai / classification: DL. g) Tam than / Hono sts examination MSE phan loa clssifcaton:.. 2, Ngoai Khoa / sue! examination Phan loa cissicaton:. 3,88n phy khoa/ 08-6YN examination Phan loa / ciessicaton: 4, Mat Eye examination: = K6t qua kham thi IWec / Result of visual acuity: + Khong kinh / without glasses: p Mt pha / Pit en PLZ Mat ti eto oun DEE. +6 kinh / wan esses: Mat phai / Right eye... Mat trai / Len eye: = Céc bénh v8 mat (néu 06) / Eye aseass any Hin chvaphatién itty. ~ Phan loai / ciassitcation: 5. Tai - Mai - Hong / Ears - nose - throat (ENT): ~K&t qua khém thinh lye / Resut hearing abt examination: + Tai trai / Lett ear: -N6i thuréng / speaking normaly + Tai phaii / rancor: NGI thurding /speating normal Noi thm / wrispering: ~ Cac bénh vé tai mai hong (néu cé) > Phan loai / ciesieston: ong nec) / Ewart w@_ Binh Thuong N6i thm / Wnispering:...| BSCKL.DANG VAN THAN!6. Ring - Ham - Mat /oortonesitotcal examnaton: = K&t qua Khim /Resut of meta! exrnation: + Ham trén /noxte:. + Ham dudi /uanatie:. = Cc bénh v8 Rang - Ham - Mat (néu 08) = Phan loai /cisieaton 7. Da li8U / Deratoogicl examination: = Phan loai /casseston: Tpowamextsac daeoes ony I. KHAM GAN LAM SANG Isuecuncat exaninarion Ho tén, chor ky a etia bac st /Full name NOI dung kham /covertotorantaton Saori of Poa 4, Xét nghiém mau [stood est: a) Céng thire mau /count Blood cas (80: = Sé long HC /rec: «$6 lugng Bach cau /wec:. = $6 lung Tiu cu /rtee. b) Sinh ha mau /soatrost BuxOng mau /tucse: c) Khac (néu 06) /oiner (ireny) 2. Xét nghiém nee tiéu / urine test: a) Burong /ucose: b) Protéin /Prtein: ¢) Khe (néu 06) /other (any) IV. KET LUAN Jconc.usion 4. Phan loai site khde /Heath cissteaton: 2. Cac bénh, tat (néu c6) / curont diseases (ray): HCMC. Ngay/aay .. NGUOI KET LUAN Dostor in charge. (Ky, ghi rd ho t&n va déng dau) (Signature, full name and seal)