O’zbekiston respublikasi sog’liqni saqlash vazirligi toshkent tibbiyot akademiyasi

O’ZBEKISTON RESPUBLIKASI
SOG’LIQNI SAQLASH VAZIRLIGI
TOSHKENT TIBBIYOT AKADEMIYASI

FAKULTET: TIBBIY PEDAGOGIKA

KAFEDRA: FAKULTET VA GASPITAL TERAPIYA
FAN: FAKULTET TERAPIYA
KASALLIK TARIXI

Bajardi:_________________________________________________

Qabul qildi:_____________________________________________
Toshkent- 2017.

1. 
   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_____
   

2. 
   Bemorning kasalxonaga tushgandagi shikoyatlari:
   

Asosiy shikoyatlar: ___________________________________________________________________ _____________________________________________________________________________________