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