Fakultet: davolash kafedra: ftiziatriya

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O’ZBEKISTON RESPUBLIKASI
SOG’LIQNI SAQLASH VAZIRLIGI
TOSHKENT TIBBIYOT AKADEMIYASI
FAKULTET: DAVOLASH
KAFEDRA: FTIZIATRIYA
FAN: FTIZIATRIYA
Bajardi:_____________________________________________
Qabul qildi:_____________________________________________
Toshkent- 2015.

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I.
Pasportga oid ma’lumotlar:
1. Bemorning familiyasi, ismi, otasining ismi __________________________________________
2. Yoshi __________
3. Ma’lumoti _______________________________________________________________________
4. Ish joyi _________________________________________________________________________
5. Millati _________________________________________________________________________
6. Turar joyi _______________________________________________________________________
7. Bemorning yo'llanmadagi diagnozi ____________________________________________________
_____________________________________________________________________________________
8. Dastlabki diagnoz _________________________________________________________________
_____________________________________________________________________________________
9.
Kelgan vaqti – ________20_____, ketgan vaqti – ________20_____
II.
Bemorning kasalxonaga tushgandagi shikoyatlari:
Asosiy shikoyatlar: ___________________________________________________________________
_____________________________________________________________________________________
Ikkinchi darajali shikoyatlar: _________________________________________________________
_____________________________________________________________________________________