ANEXA 4

Nr.../

REFERAT MEDIC DE FAMILIE

Privind situaia d-nei(d-lui)_______________________________________________ posesor al B.I./C.I.

seria___________nr_____________________cod numeric personal___________________________________
Domiciliat n localitatea_________________________str/sat________________________________________
nr________bloc____________sc________ap____________.

1. Nr.fi dispensarizare_____________,data ntocmirii_________________________

2. Diagnostic___________________________________________________________________________
___________________________________________________________________________________
_________________________________________________________-
3. Vechimea bolii
___________________________________________________________________________
___________________________________________________________________________________
_________________________________________________________________________________

4. Internri,tratamente,stare prezent(descriere)
__________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________

5.Dependent sau parial dependent de o alt

persoan______________________________________________________________________
______________________________________________________________________________________
___________________________________________________________________________________

6.Deplasbil sau nedeplasabil____________________________________________________________

______________________________________________________________________________________
____________________________________________________________________________________

7.CONCLUZII (recomandri pentru terapia social,are/nu are nevoie de supraveghere din partea unui
asistent social) _________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

ntocmit,
MEDIC DE FAMILIE
(numele i prenumele,semntura i parafa)