- Detalii
- Categorie: Documente utile
- Ultima actualizare: Sâmbătă, 20 Aprilie 2013 15:48
- Accesări: 38998
ANEXA 5
SCRISOARE MEDICALA
Nume ....................... ………………..Prenume ...............................................
Varsta .............
I Anamneza
Antecedente personale patologice ....................................................................
...........................................................................................................................
..........................................................................................................................
II. Diagnosticul medical generator de handicap
- principal .......................................................................................................
.......................................................................................................................
- altele ..........................................................................................................
.......................................................................................................................
.....................................................................................................................
......................................................................................................................
III. Certificatele medicale actuale
(se specifica nr., data, institutia emitenta si
numele medicului care a eliberat certficatul) .....................................................
............................................................................................................................
.........................................................................................................................................................................................................................................................................................................................................................................................
IV. Internari in spital
(data, institutia emitenta si diagnosticul la iesirea din spital)
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
V.Persoana - este deplasabila;
- nu este deplasabila.
Data completarii ...........................
Semnatura si
parafa medicului de familie