Dosar nr.

____________________________________
Data inregistrarii _______________________________
Numele medicului ______________________________
Sef serviciu____________________________________
FI MEDICAL SINTETIC
Nume _______________________________ Prenume _________________________________
Vrst _________
I. Anamneza
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
II. Diagnosticul medical (se specifica si nr. cod ICD 10)
- principal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
- altele
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Certificatele medicale actuale (se specific nr., data, instituia emitent i numele
medicului care a eliberat certificatul)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
III. Tratamente urmate i recomandate
Nr.
crt

Tipul tratamentelor

Medicamentoase
1
2
3
4
5
6
7
8
9

Recuperare neuromotorie
Protezare
Psihoterapie
Protezare
Psihoterapie
Recuperare psihica
Oftalmologie
Audiologie

Tratamente urmate
(scurta descriere )

Tratamente
recomandate
(se bifeaza )

10
11
12
13
14
15
16

O.R.L.
Cardiologie
Fizioterapie
Endocrinologie
Gastroenterologie
Neurologie
Altele (cu specificatie)

IV. Rezultatul tratamentelor urmate ( per ansamblu):

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
n cazul absenei oricrui tratament, enumerai motivele pe care le invoc familia :
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
V. Stadiul actual al bolii (nconjurai etapa care se potrivete): de debut, de stare evolutiv sau
stabilizat, terminal.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
VI. Concluzii i recomandri
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Data
_____________

Semntura i parafa medicului

__________________________