HEALTH CERTIFICATE – Giấy khám sức khỏe (Bản dịch mẫu)

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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

 

  1. 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…..?

  1. a) No R    b) Yes £    If answer the above question “Yes”, specify the name of diseases: ……………………………………………………………………………………………………….

……………………………………………………………………………………………………….

  1. Disease prehistory of object

Do you have one of following diseases: contagious disease, heart disease, diabetesmellitus, tuberculosis, bronchus asthma, cancer, epilepsy, mental disorder, other…..?

  1. a) No R b) Yes £     If answer the above question “Yes”, specify the name of diseases:

……………………………………………………………………………………………………….

……………………………………………………………………………………………………….

  1. Other questions (if any):
  2. Are you treating any disease? If answer this question “Yes”, list all types of drugs and dosages:

No

  1. 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)

 

  1. 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

  1. 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)

                                                                               

  1. CONCLUSION
  2. Health classification: I
  3. Other diseases (if any): Short – sighted
 

 

Date…month…year

Concluded by

(Signed and sealed)

VICE DIRECTOR

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