Scrisoare Medicala in Vederea Incadrarii in Grad de Handicap

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Scrisoare Medicala in Vederea Incadrarii in Grad de Handicap

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Nr. ................/................

SCRISOARE MEDICALĂ

Numele ................................................ prenumele .........................vârsta....................

CNP: I_I_I_I_I_I_I_I_I_I_I_I_I_I

1. Anamneza
   - antecedente personale patologice
   . .................................................................................................................................
   . .................................................................................................................................
   2. Diagnosticul medical

- principal ......................................................................................................................

   . .................................................................................................................................
   - altele ..........................................................................................................................
   . .................................................................................................................................
   3. Certificatele medicale actuale (se specifică numărul, data, instituţia emitentă şi numele
medicului care a eliberat certificatul)
   . ...............................................................................................................................
   . ................................................................................................................................

    4. Internări în spital (data, instituţia emitentă şi diagnosticul la ieşirea din spital)
   . ............................................................................
   . ............................................................................
   . ............................................................................
   5. Persoana a- este deplasabilă;
   b- nu este deplasabilă.

Data completării ............................................

Semnătura şi parafa medicului de familie
............................................

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