Anexa 1

FIA DE CONSULTAII MEDICALE

PENTRU ADMITERE UNEFS
CICLUL DE LICEN
Ziua ________luna________anul________

A. DATE DE IDENTITATE
Nume ________________________Prenume __________________________________
sexul M/F. Nscut () n anul ______________ luna ________________ ziua _________
n oraul/comuna ______________________________ judeul _____________________
fiul/fiica lui ___________________________ i al (a) ____________________________
domiciliat in judeul ______________________, localitatea _____________________, str.
_________________________________ nr._________
CNP_____________________________ , posesorul crii de identitate seria ______
nr.____________ eliberat de poliia _____________________

___
B. REZULTATELE EXAMINRII MEDICULUI DE FAMILIE

ANTECEDENTELE PERSONALE (se vor preciza boli cronice i stri patologice ce

contraindic efortul fizic sportiv)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________

APT / INAPT EFORT FIZIC SPORTIV

Semntura i parafa medicului

C. REZULTATELE EXAMENULUI CARDIOLOGIC (clinic de specialitate i

EKG de efort)
Nr. fiei ______________________Data _____________________
Concluzii examen clinic ____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________
Concluzii EKG de efort __________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________

APT / INAPT EFORT FIZIC SPORTIV

Semntura i parafa medicului

D. EXAMEN CLINIC GENERAL (efectuat de cre Comisia medical UNEFS)

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Semntura i parafa medicului

E. CONCLUZIILE COMISIEI MEDICALE DE ADMITERE

APT / INAPT EFORT FIZIC SPORTIV

Semntura i parafa medicului
2