JUDEUL

LOCALITATEA
UNITATEA SANITAR

Nr.
Telefon

FI DE CONSULTAII MEDICALE
- ADULINumele_________________________________ Prenumele_____________________________Sexul M/F
C.N.P._________________________________________________________________________________
Data naterii : 19____ luna_________ ziua________ Starea civil_______________vrsta___________
Domiciliul : localitatea______________________str.__________________________ Nr._____________
Ocupaia :___________________________ Intr.(inst.)_________________________________________
C.A.S_________________________________________________________________________________
Schimbri de:
domiciliu
loc de munc (ntrep., inst.)

Antecedente : heredo colaterale__________________________________________________________

_____________________________________________________________________________________
personale_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Condiii de munc_____________________________________________________________________
CONSULTAII, INVESTIGAII
Data
anul
luna
anul

Simptome

Diagnostic

Cod

Prescripii **)
Recomadri

*) C - cabinet, D - domiciliu
**) Se trece semntura i parafa medicului dup fiecare consultaie

Nr. zile concediu

medical
Nr. certificat

Data
anul
luna
anul

Simptome

Diagnostic

Cod

Prescripii **)
Recomadri

Nr. zile concediu

medical
Nr. certificat

Data
anul
luna
anul

Simptome

Diagnostic

Cod

Prescripii **)
Recomadri

Nr. zile concediu

medical
Nr. certificat

Data
anul
luna
anul

Simptome

Diagnostic

Cod

Prescripii **)
Recomadri

Nr. zile concediu

medical
Nr. certificat