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

Please follow and like us:

     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

Để lấy bản Word form chuẩn, các bạn vui lòng ủng hộ 10.000 VNĐ và để lại email trong lời nhắn và đường dẫn tới bài viết trên trang (Hoặc chụp màn hình donate gửi tới email: Hocquantri@quantri123.com):
Tại đây
If you want to have words translation with the correct form, please donate only 1$, write your email address in message (or take photo of donating content to email: Hocquantri@quantri123.com)
Here

 

 

 

Please follow and like us:

4 Trả lời “HEALTH CERTIFICATE – Giấy khám sức khỏe (Bản dịch mẫu)

Để lại một bình luận

Email của bạn sẽ không được hiển thị công khai. Các trường bắt buộc được đánh dấu *