ANEXA 8 A

- model -
Furnizor de servicii medicale ....................................
Medic ............................................................
Specialitatea ....................................................
Contract ncheiat cu Casa de Asigurri de Sntate ...............
Nr. contract .....................................................

FIA DE MONITORIZARE
n cazul bolnavilor cronici n ambulatoriul de specialitate pentru
specialitile clinice i recuperare, medicin fizic i balneologie

Nume: ..................... Prenume: .............................

Data naterii:
..................................................................
_ _ _ _ _ _ _ _ _ _ _ _ _
Cod numeric personal: |_|_|_|_|_|_|_|_|_|_|_|_|_|
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Cod unic de asigurare: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Sex: M/F
Adresa: .....................................................
Diagnostic: .................................................
Data lurii n eviden: ....................................
Comorbiditi: ..............................................
Factori de risc: ............................................
______________________________________________________________________
| Data | Data | Concluzii/Recomandri/Tratament | Semntura,|
| programrii| realizrii| | parafa i |
| Examinri | | | tampila |
| clinice | | | |
|____________|___________|_________________________________|___________|
| | | | |
|____________|___________|_________________________________|___________|
| | | | |
|____________|___________|_________________________________|___________|
| | | | |
|____________|___________|_________________________________|___________|
| | | | |
|____________|___________|_________________________________|___________|

Investigaii paraclinice
______________________________________________________________________
| Tip | Data | Rezultat/Data | Semntura,|
| investigaie| programrii | efecturii/Concluzii | parafa i |
| | | | tampila |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|

98