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

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: ……………………………………………………………………………………………………….

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

2. 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:

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

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

3. Other questions (if any):
4. 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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