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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