Mastlik holatini aniqlash
bo‘yicha tibbiy tekshiruvdan o‘tkazilganlik to‘g‘risidagi
__ son BAYoNNOMA
20___y. “____”____________
|
Familiyasi, ismi, otasining ismi __________________________________________________________
|
______________________________________________________________________
|
Yoshi (tug‘ilgan yili) _____________________________________________________________________
|
Qayerda va kim bo‘lib ishlaydi ______________________________________________________________
|
Kim tomonidan va qachon (aniq vaqti) tekshirishga yuborilgan _____________________________________
|
______________________________________________________________________
|
Tekshiruv o‘tkazilgan kun va aniq vaqt _______________________________________________________
|
Kim tomonidan tekshirilgan (shifokor) _____________________________________________________
|
______________________________________________________________________
|
Tekshirilish sababi: transport boshqarayotganlik vaqtida mastlik holatiga gumon, tibbiy yordam ko‘rsatish va boshqa holatlarda tekshirish (sababi ko‘rsatilsin) ___________________________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Tekshiriluvchining tashqi ko‘rinishi: kiyimlari holati, teri qoplami, jarohat (yaralanish, lat yeyish va boshqalar) _____________________________________________________________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
O‘zini tutishi: zo‘riqqan, indamas, ta’sirchan, qo‘zg‘aluvchan, jahldor, eyforik holatda, ezma, mijg‘ov, kayfiyati o‘zgaruvchan, uyqusiragan, o‘z holatidan shikoyat qiladi (aynan nimaga) ________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Es-hush holati, turgan joyiga, vaqtga va o‘z shaxsiga bo‘lgan mo‘ljali _______________________________
|
______________________________________________________________________
|
Nutq qobiliyati: fikrlarning bog‘liqligi, artikulatsiyaning buzilishi, so‘zlarni noaniq talaffuz qiladi va boshqalar _____________________________________________________________________________
|
______________________________________________________________________
|
Vegetativ qon-tomir reaksiyalari: (teri qoplamlari holati, ko‘z shilliq pardasi, til, terlash, uyquchanlik)
|
______________________________________________________________________
|
______________________________________________________________________
|
Nafas olishi: tezlashgan, sekinlashgan _______________________________________________________
|
______________________________________________________________________
|
Puls ____________ Qon bosimi__________________________________________________________
|
Ko‘z qorachig‘lari: toraygan, kengaygan, yorug‘likka reaksiyasi _______________________________________
|
______________________________________________________________________
|
Tomonlarga qaraganda nistagm _____________________________________________________________
|
Harakat doirasi ________________________________________________________________________
|
Mimikasi: bo‘shashgan, jonlangan __________________________________________________________
|
Qadam bosishi: (gandiraklangan, oyoqlarini har tomonga tashlab yuradi) _____________________________
|
______________________________________________________________________
|
koordinator sinamalar: tez burilishlar bilan yurish (burilishlarda gandiraklash) ____________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Tashen sinamasi ________________________________________________________________________
|
Romberg holatida sinama (oddiy va murakkablashtirilgan) ______________________________________
|
______________________________________________________________________
|
Aniq harakatlar (poldan tangani olish, barmoq-burun sinamasi) ___________________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Qovoqlar, til, qo‘l barmoqlarining titrashi __________________________________________________
|
______________________________________________________________________
|
Tekshiriluvchida markaziy asab tizimining organik buzilishlari, ruhiy-asab kasalliklar belgilari bor-yo‘kligi, jismoniy toliqqanlik ____________________________________________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Ilgari olgan jarohatlari (tekshiriluvchining so‘zlaridan) ______________________________________
|
______________________________________________________________________
|
Oxirgi iste’mol qilingan alkogolli ichimliklar yoki dori vositalari haqida ma’lumot: subyektiv, obyektiv (hujjatlar bo‘yicha va boshqa manbalardan) ___________________________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Og‘iz bo‘shlig‘idan alkogolli yoki boshqa moddalar hidi __________________________________________
|
______________________________________________________________________
|
Chiqarilgan nafas va organizmning boshqa biologik muhitlarida alkogol va boshqa moddalar mavjud yoki mavjud emasligi:
|
a) chiqarilgan nafas alkotester yoki Rappoport usuli yordamida tekshirildi _________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Tekshirish natijalari va o‘tkazilgan vaqti ____________________________________________________
|
______________________________________________________________________
|
Qayta tekshirish natijalari _______________________________________________________________
|
______________________________________________________________________
|
b) biologik muhit (peshob, so‘lak, lab yuzasidan, qo‘l barmoqlaridan olingan surtma) __________________
|
______________________________________________________________________
|
qaysi usul bo‘yicha _______________________________________________________________________
|
sinamaning olingan vaqti ________________________________________________________________
|
Tekshiruv vaqti va natijalari _____________________________________________________________
|
______________________________________________________________________
|
Tekshirish o‘tkazgan tibbiy xodimlar O‘z.R.JKning 238 va 240-moddalari bo‘yicha javobgar hisoblanadi va ogohlantirilgan ________________________________________________________________________
|
______________________________________________________________________
|
Xulosa: ______________________________________________________________________________
|
______________________________________________________________________
|
______________________________________________________________________
|
Tekshiruv o‘tkazgan shifokor imzosi ________________________________________________________
|
______________________________________________________________________
|
Tekshiriluvchi�ing tekshirish natijalari bilan tanishganligi haqidagi yozma bildiruvi va imzosi _______
|
______________________________________________________________________
|
|
|
|
