от 11 января 1984 г. № 37
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| Код формы по ОКУД |_5_|_1_ Код учреждения по ОКПО |
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| 1 | Министерство здравоохранения СССР | | Медицинская документация Форма № 131/у Утверждено Минздравом СССР от 11.01.84 г. № 37 | 1 |
| Наименование учреждения |
| 2 | КАРТА УЧЕТА ДИСПАНСЕРИЗАЦИИ N |_|_|_|_|_|_| (МЕДИЦИНСКАЯ КАРТА АМБУЛАТОРНОГО БОЛЬНОГО N |_|_|_|_|_| | 2 |
| 1. Фамилия, имя, отчество _____________________________________________ 2. Пол ___________________ |
| 3 | 3. Дата рождения __________________ телефон служ. ___________ 4. Адрес: район ______________________ число, м-ц, год | 3 |
| город (село) _____________________ ул. __________________ дом N ___ корп. N ________ кв. N __________ |
| 5. Место работы (учебы) __________________________ 6. Профессия, должность ________________________ |
| 4 | 7. Прикреплен для диспансеризации: | 4 |
7.1. В данном учреждении: участок N ______________________________________________ (название) |
7.2. В другом учреждении Минздрава СССР, другого ведомства ________________________ (название) |
| Год проведения диспансеризации | 1 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Прикреплен для диспансеризации | 2 | ._. | ._. | ._. | ._. | ._. | ._. | |
| Врачебный осмотр проведен (число, месяц): | |
| Терапевтом | 3 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Педиатром | 4 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Хирургом | 5 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Акушером-гинекологом | 6 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Стоматологом (зубным врачом) | 7 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Отоларингологом | 8 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Офтальмологом | 9 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Невропатологом | 10 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Осмотр акушеркой смотрового кабинета | 11 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Лабораторно-инструментальные исследования (число, месяц): | |
| Год проведения диспансеризации | | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Анализ крови | 12 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Исследование мочи: | | | | | | | | |
| общее | 13 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| на глюкозу | 14 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| на белок | 15 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Анализ кала на яйца гельминтов | 16 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Цитологическое исследование мазков | 17 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Флюорография | 18 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Тонометрия глаз | 19 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Острота зрения | 20 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Острота слуха | 21 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| ЭКГ | 22 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Маммография | 23 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Туберкулиновые пробы | 24 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Дата завершения первичного диспансерного обследования | 25 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Направлен(а) на дообследование | 26 | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | ._._._._. | |
| Впервые выявленные при диспансеризации заболевания: | |
| 198_ г. _____________________________________ 198_ г. _____________________________________ 198_ г. _____________________________________ | 198_ г. _______________________________ 198_ г. _______________________________ 198_ г. _______________________________ | |
| ЗАПИСИ В КАРТЕ МОГУТ БЫТЬ ИСПОЛЬЗОВАНЫ ТОЛЬКО НЕПОСРЕДСТВЕННО В ЛЕЧЕБНО-ПРОФИЛАКТИЧЕСКОМ УЧРЕЖДЕНИИ ПРИ ПЛАНИРОВАНИИ И ОРГАНИЗАЦИИ ДИСПАНСЕРИЗАЦИИ И СОСТАВЛЕНИИ ОТЧЕТОВ УСТАНОВЛЕННОЙ ФОРМЫ | |