16 yoshgacha bo‘lgan nogiron bolaga beriladigan
TIBBIY XULOSA
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____-son
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20___ y. “__” __________
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___________ tuman (shahar)
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1. Bolaning familiyasi, ismi, otasining ismi_______________________________
_______________________________________________________________________.
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2. Tug‘ilgan yili (oyi, sanasi) ____________________________________________
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3. Bolaning ota-onasi yoki ularning o‘rnini bosuvchi shaxslarning F.I.Sh.
_______________________________________________________________________ _______________________________________________________________________.
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4. Ota-ona yoki ularning o‘rnini bosuvchi shaxslarning doimiy yashash joyi _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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5. Tashxis (kasallikning nomi, patologik holati): ____________________________
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Asosiy ________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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Asorati _______________________________________________________________
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Qo‘shimcha tashxis ________________________________________________________
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6. Xulosa: kasallik (patologik holat) _______________________________________ ___________ taalluqli bo‘lim _____________ bandga __________ band bo‘limiga ________________________ tegishliligi
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7. Xulosaning haqiqiyligi ________________________gacha
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8. Navbatdagi tibbiy ko‘rikdan o‘tish sanasi _______________ gacha
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9. Bolaning protez-ortopediya mahsulotlari va reabilitatsiya texnik vositalarga muhtojligi:
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Ha (nomi) ______________________________________________________________
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Yo‘q.
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TMK raisi
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___________________________________
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(F.I.Sh., imzosi)
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TMK a’zolari
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___________________________________
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(F.I.Sh., imzosi)
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M.O‘.
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20__ y. “__” ______________
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