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CONG HOA.xX HOI CHU NGHiA VIET NAM. . .DQc I~p-TV' do - H~nh phiic
Ha N9i, ngay24 (hangAO nam 2019
BOYTE.S6:FfX)( IQB- BYT .
QUYETDINHV~ vi~c ban hanh m~u h6 so' b~nh an theo doi giam djnh phap y tam thAn
va m~u h6 so' b~nh an b~t bUQcChU'3b~nh tam thAn
BQ TRUONG BQ Y TE
Can cir Nghi dinh s6 75/20 17/NB-CP ngay 20/6/2017 cua Chinh phu quydinh clnrc nang, nhiern vu, quyen han va co c~u t6 chuc cua BQY t@;
Can cir Bien ban hop HQi dong phe duyet va nghiem thu m~u h6 So' Benh anthea doi giam dinh va Benh an b~t buoc chua benh tam than su' dung tai cac t6chirc giam dinh phap y tam th~n cua HQi d6ng nghiem thu va phe duyet thea Quyetdinh s6 4297IQB-BYT ngay 19 thang 9 nam 2019 cua BQ twang BQY t@;
Xet dS nghi cua Cue tnrong Cue Quan ly kharn, chua benh, BQY t@,
QUYETDINH:
Di~u 1. Ban hanh kern thea Quy@tdinh nay m~u h6 sO'b~nh an thea d5igiam dinh phap y tam th~n va m~u h6 sO'b~nh an b~t bUQcchua b~nh tam th~n.
Di~u 2. Hai (02) m~u h6 So' b~nh an ban hanh kem thea quy@tdinh nayduQ'c ap dVng t:;li cac t6 chuc giam dinh phap y tam th~n va t~i cac Co' so th\fchi~n b~t bUQcchua b~nh.
Di~u 3. Quy@tdinh nay c6 hi~u l\fc kS til ngay ky, ban himh.
Di~u 4. Cac ong, ba: Chanh Van phong BQ, Cl,lCtrucmg Cvc Quan lykham, chua b~nh, Vi~n tru'ong Vi~n Phap y tam th~n Trung uang, Vi~n truongVi~n Phap y tam th~n Trung uang Bien Hoa, Thu truong cac dO'nvi c61ien quanchiu tnich nhi~m thi hanh Quy@tdinh nay.!.
NO'i nhan:- Nhu f)i~u 4;- 89 trU'cmg (d~ b/cao);- C6ng thong tin di~n t('1" 89 Y t(~;
- Website Cvc QLKCB;- Luu: YT, KCB.
BOYTETO CHUC GIAM £)!NH PHAp Y TAM THAN (1)
I so LuD TRU:..............................
LOGOCUADdNVI
- ,BENH AN•- ,THEO 001 GIAM fllNH•
PHAp Y TAM THAN(ban hanh kern thea Quyet dinh si£CO/zgayrJ/fthangi))1iirn2019
cua B(3 truong B(3 Y ti)
NAM 20 ....
HO TEN: NAM/NG': .NAM SINH: .£)!A CHI: .VI.) ANNI.) VII;C (vai tro ella doi tuonq): .
(l).Ghi ro ten dan vi
I. HA.NH CHINH
1. HQ va ten (in hoa): ..
2. Sinh ngay: 00 00 0000 Tu6i: 003. Gioi: 0 Nam ONu 4. Ngh~ nghiep: 005. Dan toe: 006.Quoc tich: 007. Dia chi: s6 nha Thon, pho ..xs, phirong Huy~n (Q, Tx) 00Tinh, thanh phd 008. D6i tuong: 0Bi can D Bi cao DPh<;lm nhan D Bi hai
OKhac: .
Hanh vi vi pham lu~t ..9. Co quan tnrng c~u/t6 chirc tnrng cau:o Cong an OVi~n kiSm sat 0 Toa an 0 Khac ..
s6 Quyet dinh: ngay thang nam .Cua (Ten d~y du cua co quan/to clnrc tnrng c~u giam dinh): .
10. Khi c~n lien lac voi: .Dia chi: So dien thoai: .11. D~n kham luc: gio phut ngay I .I ..II. LV DO VAo (1)
III.KHAM1. Toan than: ~A h z": / h 'f
lV19C : an p u..................................................................................................................... Nhiet di): °C
BOYTETO CHU'C ClAM DJNH (1)
PHAp y TAM THAN
Anh 4x6 em
cua d6i tW)71ggiamdinh, dong dim giap
lai
PHIEUKHAMvAo THEO DCn GIA.M DJNH
PHA.P Y TAM THAN
se luu tril: .MilYT: .
Can nang: Kg
......................... ~ Huyet ap: I mmllg2. Kham tam than: Nhi tho Z'" / hutip a: an p u
..................................................................................................................... ...___~~~--------'3. Cac ca quan khac: .
4. Cho vao khoa: .5. Chll y: ..
Ngay thang mImBAc si KHAM B~NH
Ghi chu: Phdu kham vaa thea doi giam dinhphap y tam thein dU(Jcl(lp t9i Phong kham(1) Ghi ro ten dan vi
1
BOYTETO CHLrc GDPYTT (I)KHOA GIAM DJNH
Anh 4x6 em
cua d6i tuong giamdinh, dong ddu giap
lai
BENHANTHEO DOl GIAM DJNH
, '" ~PHAP Y TAM THAN
s6 luu tru:Mil YT / .I / ..
I. HANH CHINH1. H9 va ten (in hoa): ..
2. Sinh ngay: 00 00 0000 Tu6i: 003. Gioi: 0Nam ONfr 4. Ngh~ nghiep: 005. Dan toe: OO 6. Trinh dQ van h6a ..
7. Quoc tich: 00 8. Dja chi: S6 nha.. ..Than, ph6 Xa, phuong 00Huyen (Q, Tx) Tinh, thanh ph6 00
9. D6i tuong: OBi can OBi cao OPlwm nhan 0 Bi haiOKhac: ..
Hanh vi vi pham phap luat: ..10. CO' quan trung cfruo Cong an D Vi~n kiSm sat DToa an D Khac: .
Ten d~y du: .
11. Khi c~n lien lac voi: .Dja chi S6 dien thoai: .12. Vao vien/Trung tam
13. Vao khoa Giam djnh ..... :14. Ngay giarn djnh:
..............gio phut ngay / .! ..
.............. gio' phut ngay / .! ... . . .! ./ .
15. Chuyen vien:
15.1. Chuyen di: gio phut ngay .! .! ..15.2. Chuyen v~:
16. Ra vien:.............. gio' phut ngay ./. ... ./. ...............gic phut ngay ./. .. ../. .
17. K~t luau giam djnh PYTT (tai thoi diSm giam dinh):17.1. Benh chinh: .
Ma b~nh: ODDDD17.2. B~nh kenl theo: .
Mab~nh: DDDDD18. T6ng s6 ngay TDGD: DDD19.Tinh hlnh tlr vong:
20. Nguyen nhan chfnh tlr vong: .
.............. giO' ..... phut ..... ngay ... ./ .... .!........
21. Kham nghi~m tLI'thi: DC6 DKh6ng22. Tho·j gian kham nghi~m tLI'thi: Tll' gio· phut... ngay thang nam .
Ngay thang nam .....
TRUONG KHOA(1).Ghi ro ten don vi
THU TRUONG DON VI
2
B. NOJ DUNG HO saI.Ly do vao vi~n/Trung Him
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.......................................................................................................................................................................II. TOM TAT NOJ DUNG VV ANI VJ~C:( nguyen nhan d~n d~n vu ani viec, di~n bien qua trinh xay ravu ani vu viec, nhfrng bieu hien aim Iy, hanh vi cua d6i tirong tnroc, ngay tnroc, trong va sau S\T kien)
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3
III. TIEN SU
1. Ban than:
- Sue khoe (si: phat trien vi tam th6n va thi chdt tic nho din Ion, nhiing benh da mdc phai, tinh hinh h9Ctdp.kha nang lao dong cong tac, d(lc aiim tinh each tir nho din Ibn): .
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- Nghien chat hie dong tam than:
+ Loai chat (rna tuy, RuQU, khac) ..
+ Thai gian sir dung (ghi r5 s6 nam str dung, t~n su~t su dung trong ngay, lieu/I l~n su dung )
..............................................................................................................................
.................................................................................... .
- Ti~n an, tien s\I: ·..····· ··.......................................................................................................................................................................
.......................................................................................................................................................................
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2. Gia dinh:Ong, ba, cha, me, anh, chi, em ruot, can, ho hang noi ngoai co ai mac benh gi khong (chu yb¢nh thdn kinh, tam than)": .
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4
IV. KHAM B.E:NH:
1. Toan than: (th€,tg1.11g,da, niem mac, h~ thong hach, tuyen giap, vi tri, kich thu6c, s6 lUQ'ng,didong ... )
Mach: ldn/ phut
Nhiet d(J: "C
Huyh ap: .I mmHg
Nhip tho: lim/ phut
Can nang: Kg
2. Cae co quan:
+ Tu~n hoan: .
+ H6 hip: .
+ Tieu hoa: .
+ Than, ti~t nieu, sinh due: .
+ Co - Xuong khop: .
+ Tai rniii hong: .
+ Rang ham mat: ..
+Mat: .
5
.......................................................................................................................................................................
+N9i ti~t, dinh dirong va cac benh ly khac: ..
.......................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................
3. ThAn kinh
+Day th~n kinh S9 nao: ..
.......................................................................................................................................................................
.................................................................................................................................................................... , ..
+ Day mat: .
.......................................................................................................................................................................
.......................................................................................................................................................................
+ V~n dong tir chi: ..
+ Truong hrc co: .
C ' ., (nf ~)+ am glac nong, sau : .
.......................................................................................................................................................................
+ Phan x~: ..
.......................................................................................................................................................................
.......................................................................................................................................................................
4. Tam thAn
+ Bieu hien chung: .
.......................................................................................................................................................................
.......................................................................................................................................................................
-I:: Niing l\rc dinh' huong: - Khong gian ..
.......................................................................................................................................................................
- Thai gian .
.......................................................................................................................................................................
- Ban than .6
Moi truong xung quanh .
+ Cam giac: .
T · ., (Khs ~ h A h rc th . kha h 'A' 1 )+ n giac a nang n an t ire t lJC tai ac quan, cac rOI oan .
+ Cam XlIC: .
+ Tu duy: - Hinh thirc: .
- N(>idung: .
+Hanh vi tac phong: - HOSttdong co y chi: ..
- HoSttdong ban nang: .
+ Tri nho: - Nh6 may moe: ..
- Nh6 thong hi~u: .
- Kha nang phan tich: .
- Kha nang t6ng hop: .
+ Chu y: .
5. Cac xet nghiem e~n Him sang din lam: ..
+ Cac xet nghiem dn thiet:
- Xet nghiern rnau (sinh hoa, huyet hoc) D- Xet nghiern mroc ti~u D- X.quang tim, phoi thang hoac co th~ chi dinh chup nghieng D
7
- X.quang so nao thang va nghieng
- Di~nnao db- Dien tam db- Cac trac nghiem tam ly
+ Cac xet nghiem chuyen biet khac:
ooB
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8
C. TONG KET B~NH AN
1.Dien bien qua trinh theo doi giarn djnh: ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Tom t~t va k~t lu~n:a) T6m t~t trieu chtrng, hoi clurng tam than:.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................b) Cac k~t qua xet nghiem can lam sang c6 gia tri ch~n doan.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c) Ket luan giarn dinh- K~t luan thea tieu chuan y hoc........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................- K~t lu~n v~ kha nang nhan thirc va dieu khien hanh vi (trong tung thai cHim,d¢icbiet tai thai diimxciyra v~ viec, xac dinh d6i tuong giam dinh co mot trong cac tinh trang nhdn thuc, di€u khiin hanh visau day: Mdt kha nang nhdn thuc va/hoac kha nang di€u khiin hanh vi; Han chi kha nang nhdn thucva/hoac kha nang di€u khiin hanh vi (co kho khan trong nhdn thuc, lam chit hanh vi 6 cac V~I viec dansu; Dit kha nang nhdn thuc va kha nang di€u khien hanh vi):
........................................................................................................................... ,.
d) Y kiSn khac (neu co)
~ H__:_6_:_s_:__0~,PLh_i_m2'_:_a_nh_--r-,-__ +- ..---__ -iNgay ... thang ... nam 20 ....Loai S6 lUQ11g Ngiroi giao h6 so: TRV6NG KHOA @IA.M DJNH
- Cac trac nghi~m tam lY.I- Khac: , +............................ IHQ ten: .- Toan bQh6 so:
- X Quang:= 8T~~~~; d6;- Dien tam d6- Xet nghiem:
HQ ten: .Nguoi nhan ho so:
HQ ten: .
10
TO cmrc GrAM DlNHPHAp Y TAM THAN (I)KHOA GIAM DJNH ...
TO THEO nOI s6:....... S6 luu tri1':Mil YT I .
HQten DTTDGD: Nam sinh: Naml NfrBuong: Giuong: .
NGAyGIO YL~NHnlEN BIEN
...................................................................................................................................................................................................................................············1· I
(l). Ghi ro ten don vi
1 1
: 0
TO cauc GrAM DINHPHAp Y TAM THAN (I)KHOA GIAM f)INH ... PHIEU CHAM SOCs6: . sf> luu tru:
M1iYT I ..
H9 ten DTTDGD: Nam sinh: Naml NnBu6ng: Giuang: .
N' Gio-, THEO DOl DIEN BIEN THlfC HI~N Y L~NH/ KYgay phut CHAM SOC (ghi ro ho ten)
+ + t ..
........................... I
(1). Chi ro ten dan vi
12
BOYTECO' So' THl)'C HII~NBAT BUQC CHUA BeNH (1)
* * *
I SOLVUTRU:..............................
LOGOCUADON vt
BENH AN BAT BUOC• •
CHCrA BENH TAM THAN•(ban hanh kern thea Quy§t dinh s6 ngay thang ndm 2019
cua B<;5 truong B<;5 Y t§)
NAM 20....
HO TEN: NAM/NlY: .NAM SINH: .f)!A CHI: .vw ANNl) VIl;C (vai tro cua doi tuonq): .
(1).Ghi ro fen don vi
BOYTEco SOTHU'C'HIEN BAT BUOC
CHlJ'A BtNH (1) .
I. HQ va ten (in hoa): ..
2. Sinh ngay: DD DD DDDD Tu6i: DD3. Gioi: D Nam DNQ' 4. Ngh~nghiep: .5 Tinh trang lion nhan: 6. Dan toe: .7. Trinh dO van hoa 8. Quoc tich .9. Dia chi: S6 nha Then, ph6 .
Xa, phuong Huyen (Q, Tx) ..
Tinh, thanh ph6 .10. NO'i lain viec: .
11. CO'quanraquyet djnh ap dung bien phap BBCB: D Vien kiem sat DToa anSA Q A di I 'I ' -o uyet In 1: ngay tnang nam .Cua (ten d~y dll cua CQ ra quyet djnh ADBP BBCB): ..Khi c~n lien lac voi: .Dia chi S6 di~nthoai: .
12. £)6i tirong: DBi can DBi cao 0 Ph1;tl11nhanD Dinh chi DT1;tl11 dinh chi
Hanh vi vi pham phap luat: .13.£)~n kham Ilk gio phut ngay .! ..!. ..
Khoa: Giuong: .
Anh 4x6 em
cua d6i tuong giamdinh, dong ddu giap
lai
II. LY DO VAo (1)
PHIEUKHAMvAo VI:E:NBAT BUOC CHUA B:E:NH
se luu tnr:Mil YT 1 .1 .1 .
A. HANH CHiNH
III. KHAM1. Toan than: Mach: fan/phut
2. Kham tarn th~n: .
Nhiet d(3: °CHuydt ap: .1. mmllgNhip tho: fan/ phutCan nang: Kg
......................................................................................................................................... ~ __ ~ __ ~~ __ ..........,..J
3. Cac co quankhac: .
4. Cho vao khoa: .
5.Chuy: .
Ngay thang namBAC si KHAM B~NH
Ghi chu: Phdu kham vao vi¢n du9'c l(lp t(1iPhong kham(l).Ghi ro ten don vj
1
BOYTEco sa THl/C HI~N BAT BU(>C
CHO'A B~NH (1) BENH AN BAT BUOCcntrA BENH TAM THAN.
S6 luu trtr:Mil. YT / .1 .1 .
Khoa: Giirong: .
I. HQ va ten (in hoa): .
2. Sinh ngay: DO DO DODD Tu6i: DO
3. Gi6'i: 0Nam oNil' 4. Ngh6 nghiep: ..
5 Tinh trang han nhan: 6. Dan toe: .
7. Trinh dQ vim h6a 8. Quoc tjch .
9. Dia chi: s6 nha Then, ph6 .
Xa, phuong Huyen (Q, Tx) .
Tinh, thanh pho .10. Nai lam viec: .
11. Co' quan ra quyet djnh quyet dinh ap dung bien phap BBCB: 0Vi~n ki~111sat 0 Toa anse Quyet dinh: ngay thang nam ..Cua (ten day du cua CQ ra quyet djnh ADBP BBCB): .
Khi can lien lac voi: ..Dja chi s6 dien thoai: ..
12. D6i tuong: 0 Bi can 0Bi cao 0 Pham nhan
oDinh chi OT?111 dinh chi
Anh 4x6 em
cua cl6i tuong giamdinh, clang ddu giap
lai
A. HANH CHiNH
Hanh vi vi ph?111phap luat: .
13. Vao vien: gic phut ngay .1 .I ..14. Vao khoa: gio phut ngay / .I .15. Ngay GDPYTT: 1 1 ; Co guan GDPYTT: ..
KSt lu~n GDPYTT: - Benh chinh (can cir d~ ban hanh quyet djnh ap dung bien phap BBCB): ..
- B~nh kern thea (niu ea): ..16. Chuy~n vi~n:
15.1. ChuySn di: giO' phllt ngay .1 .1. .15.2. ChuySn v6:
17. Ra vi~n:
.............. gia phllt ngay .. ..1. .1 ..
.............. giO' phut ngay ... .1 ..1. ..- Benh chinh: '" ..
. Mab~nh:OODDO- B~nh kel11 thea:
Ma b~nh:0000018. Tlnh tr?ng b~nh nhan khi ra vi~n:
Kh6i10n djnh0 DO'IThuyen giiunl t?m 611dinh019. T6ng s6 ngay di6u tri: DOD
20. Tinh hinh tu vong: gio' phut ngay .1 .I ..21. Nguyen nhan chinh tu' vong: .
Ttl' vong 0
2
22. Kharn nghiem ttl' thi: C60 Kh6ng 023. Thai gian kham nghiem nr thi: gio phut., ngay thang nam .
Ngay thang nam .....
THUTRUONG TRUONGKHOA
(1) Ghi ra ten Dan vi
3
B. NQI DUNG HO saI. Ly do vao vi~n
II. TOM TAT HO sa GIAM DJNH PHAp Y TAM THAN (Qua trinh sinh truong, phat trien, tinhtrang sue khoe, benh tdt, tir khi sinh ra din khi VilD vien va qua trinh pham toi; kit ludn giam dinh phap ytam thdn)
4
III. TIEN sir1.Ban than:
- Sire khoe Him than: .
- Nghien ch~t tac dong tam than:
+ Loai ch~t (rna tuy, nrou, khac) .
+ Thai gian su dung (ghi r5 s6 nam sir dung, tftn suat su dung trong ngay, li~u/l Iftn su dung )
, ,- Tien an, tien sv: · ·· · ·..· · ··
2. Gia dlnh: Ong, ba, cha, me, anh, chi, em ruot, can, ho hang noi ngoai co at mcic benh gi khong (chit ybenh thdn kinh, tdm thdn)?: .
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.......................................................................................................................................................................IV. KHAM B~NH:
1.Toan than: (th~ trang, da, niem mac, h~ thong hach, tuyen giap, vi tri, kich thu6c, s6 lUQ'llg,didong ... ) Mach: Idnl phut
Nhiet tit): °C
Huyit rip: I mmHg
Nhip (her: ldn/ phut
Can nang: Kg.......................................................................................................................................................................
.......................................................................................................................................................................
2. Cac co'quan:
+ Tuftn hoan: .
5
· .
+ H6 h~p: .
.......................................................................................................................................................................
+ Tieu h6a: .
.......................................................................................................................................................................
+ Than ti~t nieu sinh due: .. , . , ........................................................................................................................................................................
+ Ca - Xuong khop: .
.......................................................................................................................................................................
+ Tai rniii hong: .
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+ Rang ham mat: .
.......................................................................................................................................................................
+ Mit: .
.......................................................................................................................................................................
+NQi tiet, dinh dirong va cac benh If khac: .
3. ThAn kinh
+ Day than kinh S9 nao: ..
.......................................................................................................................................................................
+ Day mit: ..
.......................................................................................................................................................................
+ V~n dong tir chi: ..
.......................................................................................................................................................................
+ Truong hrc ca: .
+ Cam giac (nong, sau): ..
+ Phan xa: .
4. Tam thAn
+ BiSu hien chung: .
.......................................................................................................................................................................
+Nang luc dinh huang: - Khong gian ..
- Thai gian .
- Ban than .
- M6i tnrong xung quanh , .
6
+ Cam giac: .
T · ., (Khe ~ nh ~ h rc th . kha h ,~. 1 )+ n giac a nang an t ire t \IC tai ac quan, cac roi oan .
+ Cam xuc:
+ Tir duy: - Hinh thirc: .
- NQi dung: .
+ Hanh vi tac phong: - Hoat dong c6 '1chi: ..
- Ho~t dong ban nang: .
+ Tri nho: _Nh6 may m6c: .
- Nh6 thong thieu: .
+ Tri tue: - Kha nang phan tich: .
- Kha nang tong hop: .
+ Chu '1: .,
5. Cac xet nghiem c~n Himsang can lam: ..
+ Cac xet nghiem c~n thiet:
- Xet nghiem rnau (sinh h6a, huyet hoc) 0- Xet nghiern mroc tieu D- X.quang tim, phoi thang hoac c6 th€ chi dinh chup nghieng D- X.quang SQ nao thang va nghieng D- Dien nao db 0- Dien tam db D- Cac tr~c nghiem Him 1'1 D
+ Cac xet nghiem chuyen biet khac:
Ngay thang nam .BAc SY DIEU TRI
7
C. TONG KET B~NH AN
Kh6il 6n dinhD Do'! thuyen giam/ tarn 6n djnh D Ttl'vongD
1. Di~n bien qua trinh di~u tr]: .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2.2. Tom t~t k~t qua xet nghiern can lam sang co gia tri chan dean:
3. Phuong phap di~u tr]: ..
2. Tom t~t va k~t luan:2.1. Tom t~t trieu chimg, hl)i clnrng tam th~n
4. K~t lu~n ella hQi dBng giam djnh4.1. K~t luan benh ehinh
4.2. Tinh trang benh ly khi ra vien
4.3. Benh kern thea (neu co):
HQ ten:
H6 so, phim, anh Ngay ... thang ... nam 20 ....f-------L-o-~--,--i '-...!---'-----------r-=-So-r-A-=-lu-g-n-g+---N-gu-O'-"i-g-:-ia-o-h-6r-s-0'-:----1TRV6NG KHOA DIEU TRl- X Quang:~Di~nn~od6;~~~~~~~~m??;....- Xet nghiem:
I· , 1··············..·········•·······- Cae nghiern tam ly .
............................................................_ .
- Khae:- Toan bl) h6 sa: HQ ten: .
8
... - ----------
co so THlJC HIBNBAT BUOCCHUA BBNH (I)
KHOA ...TO THEO DOl S6: .
S61uu trlr:Mil YT I .
Nam sinh: Nam/NuGiirong: .
HQ ten DTTDGD: .Buong: .NGAyGIO YL~NHnlENBIEN
(1): Ghi ro ten co sa
9
co so THl)'C HII;:NBAT BUQC CHUA BI;:NH (1)
KHOA .HQ ten DTTDGD: Nam sinh: Naml Nil'Buong: Giuang: .
N ' Giir, THEO DO-I DIE~N BIE'N THl/C Hl¢N Y L:E;NHI KYgay nhut CHA-M SO'C r. h h ,)P {g ira 9 ten;
PRIED CRAM SOCS6:....... S61uu trlr:MiiYT I .
(1): Ghi ro ten co so
10