CONSULTATIE PREVENTIVA LA EXTERNARE DIN MATERNITATE

NUME_____________________PRENUME______________________DN__________

EXAMEN CLINIC
FA_________FP______TEGUMENTE SI
MUCOASE________________________________________________TONUS
MUSCULAR_______________________DEZVOLTARE NEUROMOTORIE
________________________________________ORGANE GENITALE
______________________________________ ORGANE DE
SIMT____________________________
HIDRATARE_____________________

TEHNICA ALIMENTATIEI______________________________________________
EVALUAREA SURSEI DE APA SI
RECOMANDARI______________________________________________________________________
_____________________________________________________________________________________
____________________________________________
PROFILAXIA
RAHITISMULUI______________________________________________________________________
_________________________________________________________
SFATURI DE CONDUITA PENTRU PREVENIREA
ACCIDENTELOR_____________________________________________________________________
_____________________________________________________________________________________
___________________________________________--

Data

Semnatura si parafa medicului,

Semnatura mamei,

CONSULTATIE PREVENTIVA LA VARSTA DE 1 LUNA

NUME_________________________PRENUME____________________DN________

G=

T=

CIRCUMFERINTA CRANIANA=

EXAMEN CLINIC FA=

FP=
TEGUMENTE SI
MUCOASE______________________________________________________EXAMEN CORD::
RITM CARDIAC=
ZGOMOTE CARDIACE
_____________________________________SUFLURI
SUPRAADAUGATE______________________________________________SOC
APEXIAN___________________________EXAMEN PULMON: MURMUR
VEZICULAR______________________________SONORITATE
PULMONARA________________________________RITM
RESPIRATOR______________________________TONUS
MUSCULAR________________________________DEZVOLTARE
NEUROMOTORIE____________________________________________________________________
_________________ORGANE
GENITALE______________________________________________________ORGANE DE
SIMT___________________________________HIDRATARE__________________________________
_____________________________________________________________________
TEHNICA ALIMENTATIEI___________________________________________________
EVALUAREA SURSEI DE APA SI
RECOMANDARI______________________________________________________________________
_______________________________________________________________________
PROFILAXIA
RAHITISMULUI______________________________________________________________________
_______________________________________________________________________
SFATURI DE CONDUITA PENTRU PREVENIREA
ACCIDENTELOR_____________________________________________________________________
_______________________________________________________________________
Data

Semnatura si parafa medicului

Semnatura mamei,

CONSULTATIE PREVENTIVA LA VARSTA DE 2-18 luni

NUME______________________PRENUME_____________________DN__________

G=

T=

CIRCUMFERINTA CRANIANA=

EXAMEN CLINIC
FA= FP=
TEGUMENTE SI
MUCOASE________________________________________________TONUS
MUSCULAR_____________________________EXAMEN CORD: RITM CARDIAC=
ZGOMOTE CARDIACE__________________________________SUFLURI
SUPRAADAUGATE___________________________SOC APEXIAN__________________EXAMEN
PULMON:
MURMUR VEZICULAR________________________SONORITATE
PULMONARA__________________________________RITM RESPIRATOR=
DEZVOLTARE
NEUROMOTORIE________________________________________________________
ORGANE GENITALE__________________________________ORGANE DE
SIMT_____________________________HIDRATARE__________________________
EVALUARE SI CONSILIERE PENTRU
ALIMENTATIE________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________
PROFILAXIA ANEMIEI_____________________________________________________
EVALUAREA DEZVOLTARII
DENTITIEI___________________________________________________________________________
__________________________________________________________

SFATURI DE CONDUITA PENTRU PREVENIREA

ACCIDENTELOR_____________________________________________________________________
__________________________________________________________

Data

Semnatura si parafa medicului,

CMI DR. ELVADEANU VALERIAN

CONSULTATIE PREVENTIVA A COPIILOR peste 6 ani

NUME________________________________PRENUME____________VARSTA____
G=

T=

EXAMEN CLINIC : TEGUMENTE SI MUCOASE_______________________________TONUS

MUSCULAR_____________________________TESUT
ADIPOS___________________________EXAMEN
CORD_______________________________________________________________________________
_________________________________________________________________________________EXA
MEN PULMON_______________________________________________________ORGANE
GENITALE___________________________________________ORGANE DE
SIMT________________________________
EVALUAREA SI IGIENA
DENTITIEI___________________________________________________________________________
__________________________________________________________
EVALUARE
SOCIOEMOTIONALA_________________________________________________________________
___________________________________________________________
TA=
DEZVOLTARE PUBERTARA

SCREENING DEPRESIE 1.V-ati pierdut interesul sau placerea pentru activitatile

obisnuite in ultima luna? DA/NU
2.V-ati simtit trist, demoralizat sau neajutorat in ultima luna? DA/NU

SCREENINGUL OBEZITATII IMC=

CONSILIERE PENTRU STIL DE

VIATA_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________

Data

Semnatura si parafa medicului

RISCOGRAMA ADULT ASIMPTOMATIC 18-39 DE ANI

NUME____________________________PRENUME___________________VARSTA_______

FUMEAZA

DA/NU

NR. PACHETE /AN =

ALCOOL DA/NU

ACTIVITATE FIZICA DA/NU

DIETA ECHILIBRATA/ NEECHILIBRATA

TA=
DA/NU

IMC=

DECES PREMATUR PRIN BOALA CARDIOVASCULARA

COLESTEROL TOTAL=
CREATININA SERICA=

GLICEMIE=
( la persoane cu TA.> 14/9)

Risc SCORE ( TA sistolica/ cholesterol in mmol/l)= < 5%/ < 1%/ > 5%

AHC si APP de neoplazie la rude de grad. I

DA/ NU

Expunere profesionala la azbest sau aniline DA/NU

Data test Babes- Papanicolau___________

APP si AHC

de boli mintale la rudele de gradul I DA/NU

TESTUL AUDIT C
1.
Cat de des consumati bauturi alcoolice? Niciodata/lunar/2-4 ori pe luna/2-3
ori pe saptamana/4 sau mai multe ori pe saptamana

2.
Cate pahare consumati /zi atunci cand beti? 1sau2/3sau 4/5sau
6/7sau9/peste 10
3.
Cat de des beti 6 sau mai multe pahare la o singura ocazie?
Niciodata/lunar/saptamanal/zilnic
Scor B=

F=

SCREENING DEPRESIE
1.V-ati pierdut interesul sau placerea pentru activitatile obisnuite in ultima luna?
DA/NU
2.V-ati simtit trist,demoralizat sau neajutorat in ultima luna? DA/NU

RISC CONSUM DE ALCOOL DA/NU

RISC DE DEPRESIE

DA/NU

CONTRACEPTIE DA/NU

STATUSUL DE CUPLU

Data

partener stabil/nou/relatii multiple

Semnatura si parafa medicului

RISCOGRAMA ADULT ASIMPTOMATIC CU VARSTA DE 40 DE ANI SI PESTE

NUME________________________PRENUME______________________VARSTA_______

FUMATOR

DA/NU

NR. PACHETE /AN=

ALCOOL DA/NU

ACTIVITATE FIZICA DA/NU

DIETA ECHILIBRATA/NEECHILIBRATA

Risc SCORE

TA=
DA/NU

<5%/< 1%/ > 5%

IMC=

COLESTEROL TOTAL=

DECES PREMATUR

PRIN BOALA CARDIOVASCULARA

GLICEMIE=

AHC si APP de neoplazie la rude de gradul I DA/NU

Expunere profesionala la azbest sau aniline DA/NU

Data test Babes Papanicolau_________________

APP si AHC de boli mintale la rudele de gradul I DA/NU

TESTUL AUDIT-C

CREATININA SERICA=

1.
Cat de des consumati bauturi alcoolice? Niciodata/lunar/2-4 ori pe luna/2-3 ori
pe saptamana/4 sau mai multe ori pe saptamana
2.
Cate pahare consumati/zi atunci cand beti? 1 au 2/3 sau 4/5 sau 6/7 sau
9/peste 10
3.
Scor

Cat de des beti 6 sau mai multe pahare la o singura ocazie?

B=

F=

SCREENING DEPRESIE
1.
V-ati pierdut interesul sau placerea pentru activitatile obisnuite in ultima
luna? DA/NU
2.

V-ati simtit trist,demoralizat sau neajutorat in ultima luna? DA/NU

RISC CONSUM DE ALCOOL DA/NU

CONTRACEPTIE DA/NU

Data
medicului

ITS

RISC DE DEPRESIE

DA/NU

DA/NU

Semnatura si parafa