Detalii

Categorie: Documente utile

Ultima actualizare: Sâmbătă, 20 Aprilie 2013 15:48

Accesări: 41967

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