La Hijama: Nouveau Formulaire D'antécédents Médicaux Du Patient

 

Ch Bjghkh  Mauvfhu larkuchjrf o'hmtêeêofmts kêojehux kêojehux ou phtjfmt phtjfmt Ohtf 7..................... 7............................................ ............................. ......  Mak 7........................................ 7............................................................... .......................................... ................... Ohtf of mhjsshmef 7.................................... 7........................................................... .......................... ...  Mukêra of têcêpbamf têcêpbamf ou phtjfmt 7.............................. 7....................................... ......... Horfssf 7 …............................................ …................................................................... .............................................. .............................................. .............................................. ........................... .... _hjccf 7..................... 7............................................ ........................... .... ^ajos 7.................... 7........................................... .......................... ... Horfssf F-khjc 7..................... 7............................................. ............................................... .............................................. .......................... ... Bjstarjquf kêojehc pfrsammfc 77  Hvfz-vaus oêgî fu, au hvfz-vaus oêgî, c'umf ofs phtbaca`jfs

sujvhmtfs1 (Eaebfz sj auj au surcj`mfz cf ehs êebêhmt)  

Hmêkjf Hrtbrjtf Hstbkf Hccfr`jfs Hm`jmf Hmxjêtê Ehjccats shm`ujms _raudcfss bêkarrh`jqufs _raudcf Ehmefr    Adstruetjvf ebramjquf Khchojf puckamhjrf _raudcf of ch eah`uchtjam Jmsulljshmef ehrojhquf eam`fstjvf Ch khchojf of Erabm  Erabm 

                       

Oêprfssjam Ojhdâtf Fkpbysâkf ^radcâkfs fmoaerjmjfms OJTO @chueakf Bêphtjtf \JB / UJOH Bypfrtfmsjam Khchojf rêmhcf ^radcâkfs of shmtê kfmthcf C'jmlhretus ou kyaehrof Khchojf of c'uceârf pfptjquf Erjsfs o'êpjcfpsjf

       

Heejofmt vhseuchjrf eêrêdrhc Eacjtf uceêrfusf Hutrfs 1 Kfrej of oêerjrf 7

Bjstarjquf ebjrur`jehc pfrsammfc 7

Hvfz-vaus oêgî sudj umf jmtfrvfmtjam ebjrur`jehcf 1 Uj e'fst cf ehs, kfrej o'fxpcjqufr ej-ofssaus 7

_rhjtfkfmtt hetufc 1 _rhjtfkfm

 

Çtfs-vaus fmefjmtf 1 ..................... ........................ ...

Uj auj, eakdjfm of sfkhjmfs 1.................... 1......................................... .....................

Bjstarjquf saejhc 7

Eamsakkfz-vaus of c'hceaac 1 Eamsakkfz-vaus Lukfz-vaus 1 Eamsakkfz-vauss of ch ora`uf 1 Eamsakkfz-vau  

MAM MAM MAM

Uj auj, î qufccf lrêqufmef 1 .......................... .......................... Uj auj, î qufccf lrêqufmef 1 .......................... .......................... Uj auj, î qufccf lrêqufmef 1 .......................... .......................... Xufcs typfs 1 ............................................ ................................................ ....

Têsfrvê hux lfkkfs 7

Oêerjvfz vatrf eyecf kfmstrufc 7   Tê`ucjfr Jrrê`ucjfr

Kêmaphusf

Hvfz-vaus cf symorakf ofs avhjrfs pacyiystjqufs (UA^I), c'fmoakêtrjasf au taut hutrf pradcâkf `ymêeaca`jquf11 Uj auj, oêerjvfz7  `ymêeaca`jquf oêerjvfz7 

Uujvfz-vaus um trhjtfkfmt barkamhc 1 Auj Mam  Makdrf of `rassfssf `rassfssf 7 .................................... ........................................................... .................................. ...........  Makdrf o'heeauebfkfmts o'heeauebfkfmts 7 ................................. ................................. \ajx dhssf 7 ............... ............... Eêshrjfmmf 7 ................... ................... Tê`jkf quatjojfm / hppart hcjkfmthjrf7

Î qufccf lrêqufmef lrêqufmef khm`fz-vaus khm`fz-vaus fm umf gaurmêf gaurmêf11 .................... ........................................... .............................................. ............................... ........ ^rjsf o'fhu7 ............ _bê7 ............ Ehlê 7 ............ Uaoh 7 ............ Hceaac 7 ............ Uaullrfz-vaus of7 Ojhrrbêf1 Eamstjphtjam1 Drùcurfs o'fstakhe1 Jmoj`fstjam1 Ofs bhdjtuofs urjmhjrfs / pradcâkfs1 …..................................... …............................................................ .............................................. .................................. ........... Oêerjvfz vatrf lhàam of oarkjr / bhdjtuofs7

Hvfz-vaus oêgî sudj umf bjghkh huphrhvhmt 1 Uj auj, qufccf kêtbaof 7 Uâebf Bukjof Khssh`f   Hutrfs 7 Têhetjam 7....................... 7.............................................. .............................................. .............................................. .............................................. .............................................. ............................. ...... ............................................. ...................... .............................................. .............................................. .............................................. .............................................. .............................................. ....................... Thjsam 7 .................... ........................................... ............................................... ............................................... .............................................. .............................................. ................................. .......... ............................................. ...................... .............................................. .............................................. .............................................. .............................................. .............................................. .......................

 

^aurquaj vaucfz-vaus / hvfz-vaus dfsajm of Bjghkh1 Kfrej o'fxpcjqufr7

  \fujccfz fmefrecfr cfs zamfs î pradcâkfs ft jmojqufr cf mjvfhu of oaucfur7 (8> - cf pcus oaucaurfux ... 8 - cf kajms oaucaurfux) 7

 

Eamtrf-jmojehtjams 7 ch tbêrhpjf ofs vfmtausfs pfut hllfetfr ch

cjstf sujvhmtf ofs phtbaca`jfs. _aus cfs phtjfmts oajvfmt eamsuctfr cfur kêofejm hvhmt of eakkfmefr cfs sêhmefs of trhjtfkfmt._aut cf trhvhjc earparfc ft êmfr`êtjquf sfrh prhtjquê ojserâtfkfmt phr cf prhtjejfm, sfcam ch khchojf, cfs eamojtjams ft cfs mjvfhux of strfss quf cf ecjfmt prêsfmtf hvfe7 Ojhdftf Ehmefr  Eaupurfs / hdrhsjams Khssfs mam ojh`mastjquês sur cf earps _brakdasf / Fkdacjf Cheêrhtjams / uceârfs ^rfkjârfs êthpfs ou trhvhjc Dcfssurfs / ebjrur`jfs rêefmtfs \frrufs / ^chqufs sur ch pfhu ^radcâkfs of kêkajrf

Êpjcfpsjf Lrheturfs hetufccfs Fmtarsfs / laucurfs rêefmtfs Khchojfs ehrojhqufs Oyslametjam mfrvfusf Ŕoâkf sêvârf Dhrofhux hetjls Khchojf / traudcfs of ch pfhu Bypa / bypfrtfmsjam hrtêrjfccf \hrjefs

^ast-apêrhtjam o'umf `rfllf o'ar`hmf Eaup of sacfjc / eaup of vfmt Lrheturfs assfusfs _raudcfs of shj`mfkfmt ^radcâkfs of kêkajrf Khchojf eamth`jfusf Bêkarrh`jf rêefmtf

Eamsfmtfkfmt êechjrê hux sajms 7 Gf eakprfmos quf cfs jmlarkhtjams jmlarkhtjams kêojehcfs fmrf`jstrêfs fmrf`jstrêfs ohms ef larkuchjrf samt sfucfkfmt paur um ush`f jmlarkhtjammfc / tbêrhpfutjquf ft samt strjetfkfmt eamljofmtjfccfs. Gf eakprfmos quf gf oajs eamsuctfr kam kêofejm sj g'hj g' hj hetufccfkfmt au sj g'hj oêvfcappê c'umf ofs eamojtjams suskfmtjammêfs, suskfmtjammêf s, hvhmt quf gf pujssf eakkfmefr hvfe quj quf ef sajt cf trhvhjc of c'êmfr`jf. Gf eakprfmos quf cf prhtjejfm pfut eakdjmfr ofs tbêrhpjfs ft erêfr sur kfsurf um fmsfkdcf of trhjtfkfmt quj paurrhjt jmecurf c'um au c'fmsfkdcf ofs trhjtfkfmts sujvhmts7 Bjghkh (sâebf / Khssh`f / bukjof) Cf prhtjejfm h fxpcjquê cfs praeêourfs paur taus efs trhjtfkfmts. Gf eakprfmos qu'jc y hurh utjcjshtjam of chkfs ebjrur`jehcfs pfmohmt cfs praeêourfs of shj`mêfs/ bjghkh bukjof.

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 Gf oammf ch pfrkjssjam hu prhtjejfm o'utjcjsfr umf pftjtf chkf o'jmejsjam ebjrur`jehcf sur kam earps hljm of `rhttfr ch surlhef of ch pfhu ft of tjrfr umf pftjtf quhmtjtê of shm` taxjquf sfcam sh ojserêtjam  pralfssjammfccf. Gf Gf eakprfmos qu quff kfs rêsucthts pf pfuvfmt uvfmt mf phs çtrf jkkêojhts hprâs ebhquf 

trhjtfkfmt. prfmos c'fmtjârf rfspamshdjcjtê of kam trhjtfkfmt ft g'hj ebajsj o'fmtrfprfmorf ch tbêrhpjf phrGfvfmtausfs (ch Bjghkh).  G'heefptf o'çtrf pametufc î kfs rfmofz-vaus. H Hvjsfr vjsfr 4?b î c hvhmef paur ebhquf hmmuchtjam ft phyfr  cfs lrhjs o'umf sfssjam eakpcâtf sj gf m'hssjstf phs î kam rfmofz-vaus shms prêhvjs. 

 Cfs phjfkfmts samt ous î c'hvhmef.

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 Mak ou phtjfmt7 …......................................... …................................ ......... Uj`mhturf ou phtjfmt7

Ohtf 7

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