JUDEŢUL OLT CNP

LOCALITATEA CORBU
CMI DR PUENEA IONUT MARIUS NR FIŞA ______________/ DIN ___/___/2019
CTR CAS 264

FIŞA DE CONSULTAŢII MEDICALE

- ADULŢI –
Nume ____________________________ Prenume _______________________________________
Data naşterii : an ____ luna ____ zi ____ Stare civila necasatorit/a / casatorit/a
Domiciliul : localitatea _______________________str ___________________________ nr ________
Ocupaţia _______________________ BI/ CI seria ___ / nr _________
Lucreaza la _________________________ in functia de ____________________________________
Schimbari de :
Domiciliu loc de munca
____________________________________________________________________________________
__________________________________________________________________________________
Antecedente :
Heredo-colaterale : __________________________________________________________________
__________________________________________________________________________________
personale_____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________________
ALERGIC LA /GRUP SG, RH________________________________________________________
Condiţii de muncă __________________________________________________________________
__________________________________________________________________________________
CONSULTAŢII INVESTIGAŢII
Data Locul Nr zile
Anul Consul Simptome Diagnostic Prescripţii **) concediu
Luna -taţiei Recomandari medical
Ziua Nr certificat
1 2 3 4 5 6