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Documentaie medical

Formular Nr. 043/e


Aprobat de MS al RM nr.828 din 31.10.2011

Ministerul Sntii al Republicii Moldova


.I. O. Munteanu

FIA MEDICAL A BOLNAVULUI STOMATOLOGIC Nr._______


____

____________________ 2014

Nume, prenume _________________________________________________ a/n _________


Sex M / F, IDNP ___________ Profesia_____________________ Tel:__________________
Adresa la domiciliu ________________________ Locul de munca ______________________
Diagnosticul___________________________________________________________________
_____________________________________________________________________________
Acuze________________________________________________________________________
_____________________________________________________________________________
Boli antecendente i concomitente C/O-__________ Hepatit__________ Alergii__________
_____________________________________________________________________________
Evoluia actualei maladii ________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Examen extraoral _______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Examen intraoral _______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Semne convenionale:
lipsete L, rdcin R,
carie C, pulpit P,
periodontit Pt, plombat Pl,
parodontoz A,
mobilitate I, II, III (grad),
coroan Cr, dinte artificial A

Raport de ocluzie______________________ Tip de ocluzie____________________________


Starea mucoasei bucale___________________________________________________________
_____________________________________________________________________________
Investigaii paraclinice___________________________________________________________
_____________________________________________________________________________
Plan de tratament_______________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Epicriza_______________________________________________________________________
_____________________________________________________________________________
Recomandri practice____________________________________________________________
_____________________________________________________________________________
Grupa de dispensarizare__________________________________________________________
_____________________________________________________________________________
Medic curant _______________________

ef secie___________________________

Data

Zilnic
analiz, status, diagnostic i tratament la adresare

Numele medicului
curant