Scan giấy khám sức khỏe công nhân

scan giấy khám sức khỏe công nhân, hỗ trợ cho việc làm hồ sơ chất lượng, mục an toàn lao động. bổ sung cho đẹp hồ sơ an toàn lao động ivrAu c,{v xuavr suc rH6r nANu c,o Ncudr ru pir rs rudr rnd r,nN(Kbm theo Th6n8 til sd 142013TT BW ngdy 06 thdng 5 ndm 2013 s0vrd sd y rdTinh Binh Duong cOrue ry cp pH0rue xHAHa on rHon nrrAu orlc s.

ivrAu (Kbm c,{v xuavr suc rH6r nANu c,o Ncudr ru pir rs rudr rnd r,nN

theo Th6n8 til sd 14/2013/TT-BW ngdy 06 thdng 5 ndm 2013

s0vrd

sd y rdTinh Binh Duong

cOrue ry cp pH0rue xHAHa on rHon

nrrAu orlc sAr cOru

0C: KoC Phic gei Kp ong 00ng, p

Ten Hjep, Ten ryln, B0

GIAY KHAM SOC XU6r

Ho vd t€n (chir in hoa): .:i-.G.ft N V.irL Sg.n.

BpNH CUADOr TUQNG rcrAvr suc xnor

c6 ai trong gia dinh 6ng (bd) m6c m6t trong c6c bQnh: truydn nhi6m, tim

mach, cl6i th6o duong, lao, hen phii qu6n, utrg thu, dQng kinh, r6i loan t6m than,

th6 tcn benh:

2' Ti6n sfr bin thfln: ong (bd) dd/dangmic b6nh, tinh trang benh ndo

sau d6ykh6ng: Benh truycn nhi5m, bonh tim mach, d6i th6o dudrng, lao, hen ph6 qu6n,ung thu, dOng kinh, ri5i lopn t0m than, benh kh6c: a) Kh6ng tr; b) c6 tr

N6u "c6", cl6 nghi ghi cp th6 t6n bQnh:

a) ong @d) c6 dang di6u tri benh gi khong?

N6u c6, xin hdy Het ke c6c thu6c dangding vd liOu luqrrg:

xxAxSAI

1 Tidn sfr gia dinh:

TOi xin cam doan nhirng

di6u khai rr€n rl6y hodn todi

drye vdi sg thdt theo su hiriu

bi6t cria t6i

Nguoi tI6 ngh! kh6m srlc Lfr6e(Ky vd ghi 16 h9, t€n)

{u,,

,Hffi ;"nif#ffi l#ff:;#.:[*,,,

l

r Kril(M THi LrIc

- Kdt qud khdm thinh luc:

Tai trdi: N6i thudn g: 1 9-

Tai phii: N6i thrrdn g: 1

III KHAM CAN LAM SANG

vrAu cdv rnAvr s0c rcr6r nANn cHo NcrJdI rtj pt rs rudt rnd lE,N(Kbm theo Th6ng fir sd 14/2013/TT-BYT nSdy 06 thdng 5 ndm 2013

sd Y TdTinh Binh Drrong

c0rue ry cp pHOrue xnAna oR rnoR

mntn nrlc sAr cOru

DC: KoC Ph0c gat, KP ong 00n9, P Tan H0p, Tefl Uyen, BD

*22t2

GIAY KHAM SUC KHOE

He vd t€n (chic in hoa): t e V;.N N.fl- lyl

ENH culuor rUQxc KHAM sUc xnorc

NCu "c6", cl6 nghi ghi cp th6 t6n bQnh:

3 Ciu h6i khic (n6u c6):

a) Ong (bd) c6 dang di6u tri bQnh gi kh6ng? N6u c6, xin hdy ligt ke c6c thu5c dang

i::::: lt:: :*:

T6i xin cam doan nhirng

ili6u khai tr6n c10y hodn todn

tlirng v6i sg thft theo su hi6u

Nam EI Nrtr ru6i: /0 .l /.2 1 AggL

so cvnqp ho[c HQ chiiSu'.rlF.t d.6.].4.aS c6p ngdy 1 1

/Yw

r KrrAM rHi LUc

- Kdt qud khr{m thinh luc:

Taitr6i: N6i rhrrdn g: / : m; N6i thd.m: / m

_ (16n}:ll.t I_"'-tl,od, g,.; ,;./ f;; *'' *q qre* '.'.'.' '/i.i f .*

t,

ao fr^: fit

TII KHAM CAN LAM SANG

1 PhAn Ioqi sric kh6e:

,ttpt

a Phen lo4i srlc kh6e theo quy tlinh t4i Quydt tlinh sd 16l3EYT-QD hoic ph6n lo4i srlc kh6e theo quy tlinh crla

bQ ti6u chudn srlc kh6e chuy€n ngnnh tldi vdi tnrdng hgp khdm srlc kh6e chuy€n nginh

5 Ct i ro cdc bQnh, tft, phuong 6n tlidu ri, phuc tr6i ctutc nlng ho{c gidi thiQu khdm chuy€n ktroa dd ttr6m b0nh, chf,a bQnh

?

4

DAK wxArq

.sAl(

vrAu cr,{y rru(vr s0c ru6r nANn cHo NcUdr rU pt rs rudr rnd lE'N(Kdm rnro iiins t,r ,d l4/2u3rrr-ByT nsdy 06 thdng 5 ndm 2013

sO v rf ctta BQ truhng nO Y td)

sB Y t6tinh Binh Dudng

c0rue ry cP PHONc rnAHa oR xHoR

uris nfc s-ir cos

0C: KoC Ph0c oet, KP ong oong, P Tan Hiep, Ten WEn' BD

DQc lflP - TU do - Hgrh Phtic

0T: 02i4.3613.115 - MST: 3702471213

56: /GKSK-HP

cIAY KHAM SIIC KH6E

Hq vd tdn (ch& in hoa): Ui V'i'U'nd Nft

pNIr cuADOI TIIqNG ruAivr stlc KIrOE

N6u "c6", d€ nghi ghi cp thO tOn benh:"""

3: ce" h6i kh6c (n6u c6): '

,6,xin hdy Het kc c6c thu.c danga) Ong (be) c6 dang di0u tri benh gi kh6ng? NOu c

dung vi 1i0u lugng:

T6i xin cam doan nhimg

di6u khai tr6n t10Y hodn todn

dung v6i sg thflt theo sg hi0u

I KHAM THE LUC

Chi6u cao: cm; CAn ndng: kg; Chi sdBMI:

M4ch: (-1 1dn/phrit; Huydt ap, ,1.2C/

Tai tr6i: N6i thrrdne 1 r

Tai phii: N6i thtrdn E: 1 2

- Cdc bQnh vd tai mfri hong (ndu c6):

III KHAM CAN LAM SANG

Sd tugng Tidu cdu:

h) Sinh h6a m6rr: DrliJns mdu: -

IV KET LUANTV KET LUAN

L PhAn lo4i srlc kh6e: fr.

,lf{.,

a Phan loai sfc kh6e theo quy rlinh t+i Quydt dinh sd 1613/BYT-QD ho4c phtn lo4i sric kh6e theo quy clinh crla

bQ ti6u chudn srlc kh6e chuy6n nginh tldi vd'i tn/dng hgp khdm s(rc kh6e chuy€n nginh

s Ghi ro cdc bQnh, tQt, phrrong an Ai6u tri, phuc hdi ctulc ning ho4c gidi thiQu kh6m chuy6n khoa dd kh6m bQnh,

chfra bQnh

uxAru/t-rrjc

1

vrAu cdv rnAu s0c rn6n nANn cHo NctIdI rtj pt rs rudr rnd lnN

(Kdm theo Th6ng fir sd 14/2013/TT-BYT nSdy 06 thdng 5 ndm 2013

C6 ai tong gia tlinh 6ng

m4ch, d6i th6o dudmg, lao, hen

NII CUA OOI TUONC TTTANA STIC XUOT

@d) mic mQt trong c6c bQnh: truydn nhi6m, timphti quin, ung thu, dQng kinh, rtii loa, t0m thAn,

tr; b) C6 tr; NOu "c6", dd nghi ghi cuth6 t€n benh:

2 Tidn sfr bin thfln: flng Od) ddldang mdc bQnh, tinh tr1ng benh niro sau ddykhdng: Benh truy6n nhi6m, benh tim m4ch , dhi th6o ducrn g, lao, hen phi5 quin,ung thu, dong kinh, toi lopn tdm thAn, benh kh6c: a) Kh6ng tr; b) C6 tr

N0u "c6", dC nghi ghi cu th6 t6n bQnh: '

3 C0u hdi kh6c (n6u c6):

a) Ong 16e) c6 dang dieu tri benh gi kh6ng? N6u c6, xin hdy het ke c6c thu6c dangding vd hdu lugng:

b) Ti0n su thai sin (DOi vdi phg nfi): ' - '.

T6i xin cam doan nhimg

cli6u khai tr6n il6y hoin todn

tlrng vdi sg thft theo s1r hiOu

rrr KHAM cAN rAu sANc

cria Bdc si

r -Ler ngffgm m6u:

a) COng thrlc m6u: Sd luone HC:

Sd lrrong Bach cdu:

Sd lrrong Tidu cdu:

b) Sinh h6a mdu: Dtrdng mdu:

a Phan loai sri'c kh6e theo quy dinh t4i

Quydt dinh sd 1613/BYT-QD ho6c ph6n toai srlc kh6e theo quy tlinh crla

b0 ti6u chudn srlc kh6e chuydn nganh a& vdi tnrdng hQp kh6m srti ti,oe chuyCn ngdnh

'.grl': c6c bQnh, tft, phrrjng ar"aie, oi, ilr,;;dffi;.';il;;'iii,rr,e, kh6m chuy6n khoa dd khdm bQnh, chfra b€nh

sa Y rdrinn Binh Dudng

oONG TY CP PHONG KHAM DA KHOA

oi,ioc pr'o, out, KP Ons Dong, P Ten Higp' Ten Wen' BD

- ' DQc taP - TrY do - H?nh Phric

0T: 0274.3513.1 15 ' MST: 3702471213

Sd: /GKSK-HP

crdv KHAM s0c rn6p

He vd tdn (chtr in hoa): 't ]il'ft'nl""!'filI" Mfl{}'t

BpNH CUa.Oor rugNc xnArvr suc ruor

1 Tiiin sir gia tlinh:

N6-u "c6", dii nghi ghi cu thi5 t6n bQnh:"""

rb'xin hdv het ke cic thuoc danga) Ong (bd) co dang di0u tri bQnh gi kh6ng? NOu t

TOi xin cam doan nhfmg

di€u khai tr0n tl6Y hodn todn

dung vdi sY thPt theo sg hiOu

liA+ ^,ia fAi

Tai tr6i: N6i thudng: 1 *

Tai phii: N6i thudn e, / L ,

- Cdc bQnh vd tai mfii hong (ndu c6):

IIr KHAM cAN r,Avt sANc

A w.

Ui ,iC, frra, sfc kh6e ctruy6n ngdnh d&-vdi trudng hQp kh6m srlc kh6e chuy6n nginh

BOYTE

CONG ry cP PHONG KHAM DA KHOA

nrni.ru DrIc sar cou

0C: KDC Phic oat, KP ong 00ng, P Tin Hiqp, Ten Won, BD

C6 ai frong gia tlinh

mpch, t16i th6o dudmg, lao,

tr; NOu "c6", dd nghi ghi cp

vrAu cl(v KHAM srlc xs6E DANH cHo Ncudr rrj pt ls rudr rRd r,EN

(Kim theo Thing tu sd l4/2013/7'T-ByT ngdy 06 thdng 5 ndm2013

Ho vi t€n (chir in hoa): n{G$ O *LTt*.uf.4W

th6 t6n b6nh:

2 Ti6n sfr bin thin: 6ng @d) dd/dang mic bQnh, tinh trang

kh6ng: Benh truy6n nhi6m, benh tim mpch, dili th5o dudrng,

ung thu, dQng kinh, r6i 1o4n tdm thAn, bQnh kh6c: a) Kh6ng

, bQnh nio sau ddylao, hen ph6 quin,

tr; b)C6 tr

NCu "c6", c16 nghi ghi cp thi5 t6n bQnh:

3 Cflu h6i kh6c (;6; ;i;

a) Ong @d) c6 dang di6u tri b$nh gi kh6ng? N6u c6, xin hdy liQt kC c6c thu6c dang

dung vd hdu lugng:

b) Ti6n su thai sin (DOi voi phs nfr):

.A ,.

ngdy thdng r ndm

Nguori tI6 ngh! khfm'sri,c kh6e (Ky vd ghi rd hq, t€n)

TOi xin cam doan nhimg

di6u khai tr6n t16y hodn todn

dung v6i sg thdt theo sg hi6u

r KHAM THi LrJc

Ctridu cao: cm; Cdn n{ng: kg; Chi sd BMI:

Mach: fr1 tdn/phrit; Huydt ap: at/,C.J 6.e mmHg

Tai trdi: N6i rhudn g: /.n

-Tai phii: N6i thudn g: / )

- Cdc bQnh vd tai mfri hong (ndu c6):

rrr KHAM cAN r,Awr sANc

Sd lrrong Tidu cdu:

b) Sinh h6a m6u: Dudne m6u:

rvrAu crAv xnAu stlc rn6p oANu cHo NctJdI rrJ pt rs rudr rnd IEN

(Kim theo Th6ng tu sd 14/2013/TT-BYT ngdy 06 thdng 5 ndm 2013

sd Y TdTinh Binh Dudng

c0rue rv cp pH0rue rHAu on xHoe

nrrAn DfIc sAr cou

OC: KoC Ph[c 0ar, KP ong 00n9, P Trn Hi0p, Tin Won, BD

2 Tiiin sfr bin thfln: Ong (be) ddldang mic bQnh, tinh tr4ng benh ndo sau ddykh6ng: Benh truy6n nhi5m, bQnh tim m4ch , d i th6o duln g, lao, hen phi5 qu6n,

ung thu, dQng kinh, r0i top, tdm thdn, benh kh6c: a) Khdng tr; b) C6 tr

NOu "c6", c16 nghi ghi cp thiS t0n benh:

3 CAu h6i khSc (n6u c6):

a) Ong (bd) c6 dang dieu tri benh gi kh6ng? N6u c6, xin hdy liQt ke c6c thu6c dangdring vd 1i6u lugng:

b) TiAn sri thai san @6i voi phs nt):

T6i xin cam doan nhimg

tti6u khai tr6n tl6y hoi,m tod,n

dune vdi sg thflt theo sU hi6u

Gi6i: Nam EI Nt tr tu6i:

so cvnlo hoflc HQ chitiu:4[6a6.v39 cip ngity/L(.l.oll laHf:.

;::'4$^qt^n^, Affia::D'q: ::: ::::::

- Kdt qu6 kh6m thi lrrc: Kh6ng kinh: M6t ph6i: .!.1/'LoMertrai: .lg/.l.a

- Cdc bQnh vd mdt (ndu c6):

Phdn loai: L

III KHAM CAN LAM SANG

4

5

ndm

Phq lqc 1nnAu crdv KHAM srlc ru6E DuNG ciro Ncrjdr rU otr rs rudr rnd r,0N

(Kam theo Th6ng tr, s6'LAZAfiTT-BYT ngiy 06 thdng 05 ndm 2013

cta pdr IUONG xnAu sUc rn6n

C6 ai trong gia dinh 6ng Gn) miic mQt trong cdc bQnh: truydn nhi6m, tim mach,ddi th6o drtdng, lao, hen phd quin, utrB thtr, dQng kinh, rdi loan t6m thdn, bQnh khric,

a) I{h6ng tr b) C6 tr Ndu "c6", dd nghi ghi cu thd t6n benh:

2 Ti6n sr? bin thAn: Ong (bn) d1ldang mdc bQnh, tinh trang bOnh ndo sau dAykh6ng: BQnh truydn nhi6m, bQnh tim mach, d6i thrio dudng, Iao hen phd quin, utrB

th4 dQng kinh, rdi loan tAm thdn, bQnh kh6c: a) Kh6ng tr b) C6 tl

Ndu "c6", dd nghi ghi cu thd tOn bQnh:

3 Cflu h6i kh6c (ndu c6):

a) Ong (bn) c6 dang didu tri benh gi khOng? Ndu c6, xin hiy liet ke cdc thuoc d-ang

dirng vi ti6u lttong:'

cQxc soa xa HQr cHir NcHiA vr$r NAn{

DQc lflp - T{ do - H+oh phric

b) Ti6n sir thai sin (Ddi vdi phu nir):

, ngay thring ndmNgudi d6 nghi khrim srfc'kh6e

2 TOn cfia co s& khrim srlc kh6e

(Ky ye ghi rO ho, t6n)

'h Hs vi t6n (chn in hoa): D.Uld.N.fr M.i.fl.tt S fri

Gidi: Nam fi Nn tr rudi: 06.lfi6llt0+ h

Sd CMND hodc H6 chidu' il.8'?"[+.3%fr ctio ngiv: JA '.t ffit.i0,1.6

\

Sd CMND hodc H0 chidu' l.8rt[+32/.0

iffip-x$" tui, ).divr, pffil ,.4K,n"I ffi , h.,\fi plddq

1 Ti6n stl

rr KrrAM tAwt sANG

Tai trdi: N6i thudne, /0

Tai phdi: N6i thudng: 1

- Cdc bOnh vd tai mfri hgng (ndu c6):

rrr KHAM cAN r,ann sANc

r

o

Phan loai st?c kh6e theo loai I ho{c lI ho{c III ho{c IV hodc V theo quy dinh t4i euy6t dinh s6 I 613/ByT - eD

hoac phAn loai suc khoe theo quy clinh cria b6 ti6u chu6n sirc khde chuy6n ngdnh Ai5i vOi truong hqp kh6m sirc

Sd luong Bach cdu:

Sd lrrong Tidu cAu:

b) Sinh h6a mdu: Dudne m6u:

ASAT (GOT): .

Kh:ic (ndu c6):

AI"AT (GPT)c)

Z.X;AI nghiQm nr/6c tidu:

T9i xin cam doan nhims

didu khai tr6n d6y fr"a, i"iT

,Ulrt vdi sg thgt theo ,u friSu

oret cua t6i.

- Kdt qud kh6m thi trrc: Kh6ng kinh: udt pn6L I M6ttr6i:

L*-c6 kinh: vt6t prrii: u.Lc Mdt tr6i: Lrc

- C6,c bQnh vd m6t (ndu c6): /.{).u

/#(

5 Tai-Mfii-Hgng

- Kdt qui kh6m thinh h/c:

Taitrdi: N6i thrrdng: ,p6 m; N6i thdm: - r2;i m

Tai phii: N6i rhudng: 1 m; N6i thdm: A* .\ m

- Cdc bQnh vd tai mfri hong (ndu cd): /./:t:dir:;

- Phdn loai: /,/.h.'/ .

6 Rdng-Him-M{t

- Kdt qui khdm: + Hdm tr6n:

i.t ?4r t

rII KIIAM cAN t Ana sAxc

a Phan loai sfc kh6e theo quy ttinh

t4i Quydt dinh sd.l6l3iByr-eD hoac ph6n loai srlc

kh6e theo quy dinh cfia b6 ti€u chudn srlc kh6e chuv6n ,ga"l ali'"oi fiqn, hop kh6m -,r ilrai chuy.n nginh

l#h:"# b6nh, t6t, phuone a,"a,e,G, il;;diil.?il;il !'#,"*,e, kh6m chuyen khoa trd kh6m bQnh,

1 Xet nghiQm m6u:

c) Kh6c (ndu c6):

3 Chdn do6n hinh 6nh: