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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