THE CONTROL CARD

THE CONTROL CARD

of dispensery observation

Doctor´s Name _______________________ Position ________________________________ Date of the registration______________________ Take off of the registration date________________ The reason of the taking off of the registration date______________________________________

A code or № of our patient´s card (child´s development card)_____________________________________________ 1.Diagnosis due to which patient is registered______________ 2. Diagnosis is established first time in life________________ (date) 3. code of ICD-10 _________________ 4. Accompanying diseases _______________________ ___________________________________________________ 5. Pathology is revealed: 5.1. when patient visits doctor 5.2. during check-up

6. Code of privilege

7. Surname, Name, Father´s name______________________________________________________________________

8. Sex: М/F 9. Date of birth______________________

10. Address ______________________________________________________________________________

11. Place of work (study, preschool) _____________________________________________________

12. Profession (position) _________________________________________________________________________

13. The control of visits____________________________________________________________________________

Date of visits

Appointed visit of patient

The date of patient´s visit

Date of visits

Appointed visit of patient

The date of patient´s visit

Date of visits

Appointed visit of patient

The date of patient´s visit

Date of visits

Appointed visit of patient

The date of patient´s visit

Date of visits

Appointed visit of patient

The date of patient´s visit

in the reversible side

reversible side of form № 030/u

14. Changing of diagnosis, accompanying diseases, complications____________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15. Kind of treatment (prophylactic, transferred to the consultation, to daily establishment, hospitalization, sanatorium treatment, employment, invalidity)

№	begining date	ending date	Examination

Doctor´s signature_________________________