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1. Bolaning familiyasi, ismi, otasining ismi ___________________________
2. Tug‘ilgan yili _____________________________________________________
3. Bolaning ota-onasi yoki vasiysi (homiysi)ning familiyasi, ismi-sharifi ___________________________________________________________________
4. Ota-onaning yoki vasiy(homiy)ning doimiy yashash joyi _________________ ___________________________________________________________________
5. Tashhis (kasallikning nomi):
Asosiy _____________________________________________________________
Asorati ____________________________________________________________
Qo‘shimcha tashhis ____________________________________________________
6. Xulosa:
7. Xulosaning haqiqiyligi ____________dan _____________gacha
8. Navbatdagi tibbiy ko‘rikdan o‘tish sanasi
9. Bolaning maxsus asbob-uskuna, moslama va harakat uchun vositalarga muhtojligi:
Ha (vositaning nomi) ______________________________________________
Yo‘q.
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