Mastlik holatini aniqlash bo‘yicha tibbiy tekshiruvdan o‘tkazilganlik to‘g‘risidagi __ son BAYoNNOMA |
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Familiyasi, ismi, otasining ismi __________________________________________________________ |
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Yoshi (tug‘ilgan yili) _____________________________________________________________________ |
Qayerda va kim bo‘lib ishlaydi ______________________________________________________________ |
Kim tomonidan va qachon (aniq vaqti) tekshirishga yuborilgan _____________________________________ |
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Tekshiruv o‘tkazilgan kun va aniq vaqt _______________________________________________________ |
Kim tomonidan tekshirilgan (shifokor) _____________________________________________________ |
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Tekshirilish sababi: transport boshqarayotganlik vaqtida mastlik holatiga gumon, tibbiy yordam ko‘rsatish va boshqa holatlarda tekshirish (sababi ko‘rsatilsin) ___________________________________________ |
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Tekshiriluvchining tashqi ko‘rinishi: kiyimlari holati, teri qoplami, jarohat (yaralanish, lat yeyish va boshqalar) _____________________________________________________________________________ |
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O‘zini tutishi: zo‘riqqan, indamas, ta’sirchan, qo‘zg‘aluvchan, jahldor, eyforik holatda, ezma, mijg‘ov, kayfiyati o‘zgaruvchan, uyqusiragan, o‘z holatidan shikoyat qiladi (aynan nimaga) ________________________ |
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Es-hush holati, turgan joyiga, vaqtga va o‘z shaxsiga bo‘lgan mo‘ljali _______________________________ |
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Nutq qobiliyati: fikrlarning bog‘liqligi, artikulatsiyaning buzilishi, so‘zlarni noaniq talaffuz qiladi va boshqalar _____________________________________________________________________________ |
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Vegetativ qon-tomir reaksiyalari: (teri qoplamlari holati, ko‘z shilliq pardasi, til, terlash, uyquchanlik) |
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Nafas olishi: tezlashgan, sekinlashgan _______________________________________________________ |
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Puls ____________ Qon bosimi__________________________________________________________ |
Ko‘z qorachig‘lari: toraygan, kengaygan, yorug‘likka reaksiyasi _______________________________________ |
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Tomonlarga qaraganda nistagm _____________________________________________________________ |
Harakat doirasi ________________________________________________________________________ |
Mimikasi: bo‘shashgan, jonlangan __________________________________________________________ |
Qadam bosishi: (gandiraklangan, oyoqlarini har tomonga tashlab yuradi) _____________________________ |
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koordinator sinamalar: tez burilishlar bilan yurish (burilishlarda gandiraklash) ____________________ |
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Tashen sinamasi ________________________________________________________________________ |
Romberg holatida sinama (oddiy va murakkablashtirilgan) ______________________________________ |
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Aniq harakatlar (poldan tangani olish, barmoq-burun sinamasi) ___________________________________ |
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Qovoqlar, til, qo‘l barmoqlarining titrashi __________________________________________________ |
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Tekshiriluvchida markaziy asab tizimining organik buzilishlari, ruhiy-asab kasalliklar belgilari bor-yo‘kligi, jismoniy toliqqanlik ____________________________________________________________ |
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Ilgari olgan jarohatlari (tekshiriluvchining so‘zlaridan) ______________________________________ |
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Oxirgi iste’mol qilingan alkogolli ichimliklar yoki dori vositalari haqida ma’lumot: subyektiv, obyektiv (hujjatlar bo‘yicha va boshqa manbalardan) ___________________________________________ |
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Og‘iz bo‘shlig‘idan alkogolli yoki boshqa moddalar hidi __________________________________________ |
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Chiqarilgan nafas va organizmning boshqa biologik muhitlarida alkogol va boshqa moddalar mavjud yoki mavjud emasligi: |
a) chiqarilgan nafas alkotester yoki Rappoport usuli yordamida tekshirildi _________________________ |
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Tekshirish natijalari va o‘tkazilgan vaqti ____________________________________________________ |
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Qayta tekshirish natijalari _______________________________________________________________ |
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b) biologik muhit (peshob, so‘lak, lab yuzasidan, qo‘l barmoqlaridan olingan surtma) __________________ |
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qaysi usul bo‘yicha _______________________________________________________________________ |
sinamaning olingan vaqti ________________________________________________________________ |
Tekshiruv vaqti va natijalari _____________________________________________________________ |
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Tekshirish o‘tkazgan tibbiy xodimlar O‘z.R.JKning 238 va 240-moddalari bo‘yicha javobgar hisoblanadi va ogohlantirilgan ________________________________________________________________________ |
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Xulosa: ______________________________________________________________________________ |
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Tekshiruv o‘tkazgan shifokor imzosi ________________________________________________________ |
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Tekshiriluvchi�ing tekshirish natijalari bilan tanishganligi haqidagi yozma bildiruvi va imzosi _______ |
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