ANEXA 5 Scrisoare medicala
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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