Tratament

Data

Act terapeutic

Medic

Semnatura
pacient
______________________________________________________________________________________________________________________

Fisa nr. ___________ din ______________________________

Medic _________________________________
1. Date personale pacient
Nume ___________________________ Prenume ____________________________ Data naterii ____________________________
C.N.P. _____________________________ Seria carnet asigurat ________________________Domiciliul: Judeul
______________________ Localitatea __________________________ Strada ________________________ Nr. _______ Bl. _______
Sc. ________ Et. ________ Ap. _______ Ocupaia ______________________________________ Loc de munc
________________________________________ Tel._______________________ Email: _________________________________________

Oglinda dentara

Jurnal de plata
Data

Suma

Achitat

Rest plata

55 54 53 52 51
18 17 16 15 14 13 12 11

61 62 63 64 65
21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41
85 84 83 82 81

31 32 33 34 35 36 37 38
71 72 73 74 75

2. Diagnostic __________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
3. Plan de tratament _______________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
DECLARAIE:
Menionez c mia fost explicat pe nelesul meu diagnosticul, planul de tratament i costul
estimativ, i mi asum i nsuesc tratamentele propuse i voi respecta indicaiile date. Am
luat la cunotin despre eventualele riscuri, accidente i complicaii care pot interveni pe
parcursul tratamentului i dup finalizarea lui i declar n deplin cunotin de cauz
c mi le nsuesc n totalitate, aa cum miau fost explicate de Dr. _________________________
DATA,

- 4-

SEMNTURA,

-1-

CHESTIONAR DE EVALUARE A STRII GENERALE

Subsemnatul (a) _________________________________________________________________
domiciliat () n _______________________________________________________________________
legitimat () cu B.I./C.I. seria ____ nr. ____________, CNP _______________________n calitate de:
1. Pacient () prezentat () _________________________________________________________
2. Reprezentant legal al _____________________________________________ n vrst de
____________ prezentat ()______________________________________________________________
3. Aparintor (so/soie, frate/sor, __________________________) al pacientului (ei) prezentat ()
__________________________________________________, declar urmtoarele date:
Suntei/este posibil s fii gravid1?da nu
Dac suntei gravid, precizai ce vrst are sarcina (n sptmni)

________

Suntei n perioada ciclului menstrual1?da nu

Suferii de alergii sau intolerane medicamentoase sau nemedicamentoase? da nu
Dac rspunsul este afirmativ, precizai la ce anume: ____________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Urmai un anumit tratament (medicamentos, homeopatic, fitoterapic etc.)? da nu
Dac rspunsul este afirmativ, precizai medicamentul/produsul i doza administrat:
______________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Ai urmat tratament cu antibiotice n ultimele dou sptmni? da nu
Dac rspunsul este afirmativ, precizai medicamentul i doza: ____________________________________
Urmai tratament cu anticoagulante? da nu
Dac rspunsul este afirmativ, precizai:
a) medicamentul i doza administrat: ________________________________________________________
b)valoarea INR:_________________
Urmai tratament cu: Fosamax, Fosavance, Actonel, Bonviva, Zometa, Aclasta(bifosfonai)? da
nu
Dac rspunsul este afirmativ, precizai:
a) medicamentul i doza administrat:________________________________________________________
b) calea de administrare:intravenoas; oral.
c) de ct timp urmai acest tratament (luni/ani) ______________
d) valoarea cross-laps:______________
Suferii sau ai suferit de vreo boal acut sau cronic? da nu
Dac rspunsul este afirmativ, precizai ce boal (i):
- boli congenitale: ______________________________________________________________________
- boli profesionale: ____________________________________________________________________
- boli de inim: angin pectoral; infarct miocardic (precizai cnd:__________________)
aritmii (fibrilaie etc.) blocuri insuficien cardiac (precizai clasa NYHA __________)
valvulopatii (precizai care: ______________________________) endocardit infecioas;
intervenii chirurgicale cardiace (precizai ________________________________________________
________________________________________________________________________________
altele: ___________________________________________________________________________
- boli vasculare: arteriopatie obliterant; tromboflebit; hipotensiune arterial

hipertensiune arterial (precizai cea mai mare valoare tensional avut ___________ mmHg)
accident vascular cerebral (precizai cnd: _____________); altele: _________________________
- boli ale aparatului respirator: astm bronicemfizem; bronitcr.; TBC (precizai dac ai
urmat tratament ______________); altele: _______________________________________________
- boli digestive: gastrite/ulcer gastro-duodenal; altele: _______________________________________
- boli hepatice: steatoz hepatic; hepatit cronic; ciroz; altele: _________________________
- boli renale: insuficien renal (precizai dac urmai hemodializ ____________________)
- diabet: tratament cu insulin; tratament cu antidiabetice orale
- boli endocrine: hipotiroidie; hipertiroidie; altele: _______________________________________
- boli reumatismale: poliartrit reumatoid; colagenoze; altele: _____________________________
- boli scheletale: osteoporoz; altele: ___________________________________________________
- boli neurologice: epilepsie; altele: _____________________________________________________
- boli psihice: depresie; schizofrenie;altele: _____________________________________________
- manifestri neuro-vegetative: atacuri de panic
- boli hematologice: anemie; thalasemie; leucemie acut; leucemie cronic;
hemofilie; trombocitopenie; boala von Willebrand; altele: _____________________________
- boli infecioase: hepatit viral B, C, D; HIV; altele: _____________________________
- neoplasme: __________________________________________________________________________
- alte boli: _____________________________________________________________________________
Ai mai fost supus() unor intervenii chirurgicale? da nu
Dac rspunsul este afirmativ, precizai ce intervenie (i): _______________________________________
_____________________________________________________________________________________
Dac rspunsul este afirmativ, precizai tipul de anestezie: loco-regional; sedare;
general; altul: ____________________________________________________________________
Dac rspunsul este afirmativ, precizai dac n timpul sau dup intervenia chirurgical au aprut incidente
nu da (precizai ce anume): ___________________________________________________________
_____________________________________________________________________________________
Ai primit transfuzii de snge/derivate: da nu
Vi s-au mai efectuat tratamente stomatologice? da nu
- mi s-au realizat tratamente stomatologice fr anestezie, cu anestezie local,
cu anestezie local i sedare inhalatorie, cu anestezie local i sedare intravenoas,
cu anestezie general.
La tratamentele stomatologice anterioare au aprut accidente/incidente sau complicaii la utilizarea
anestezicelor? da nu
- au aprut: lein, grea, alergii, altele _______________________________________________
Suntei/ai fost consumator de:
- tutun?: nu da (precizai ce cantitate i ct timp ai fumat/fumai): ____________________________
- alcool?: nu; da (precizai ce cantitate i ct timp ai consumat/consumai alcool): ________________
_______________________________________________________________________________
ai avut problema atunci cnd nu ai mai consumat alcool? __________________________________
- droguri?: nu da (precizai ce drog/droguri utilizai): _______________________________________
Certific c am citit i neles pe deplin cele de mai sus i declar c datele furnizate de mine n acest
chestionar sunt reale i complete. mi asum ntreaga responsabilitate pentru incidente sau complicaii ce
pot s apar n eventualitatea c aceste date sunt false sau incomplete.
Data completrii:

Semntura declarant2

______________

n cazul reprezentantului legal/aparintoruluise va completa numele i prenumele n clar, precum i calitatea fa de

pacient.
2

Vor completa doar persoanele de sex feminin aflate la vrsta fertil (14-55 de ani).

- 2-

-3-