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Anexa nr.

5
la Hotrrea 2 / 4 din 2 decembrie 2011
a Comisiei speciale de desfurare
a alegerilor pentru funcia de
Preedinte al Republicii Moldova
Model

CERTIFICAT DE SNTATE
Numele, prenumele___________________________________________________
Data naterii ________________________________________________________
Locul de munc, funcia_______________________________________________
Concluzii privind starea sntii:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
(Anexa - pentru dosar)
Medicii, membri ai Comisiei:
Numele, prenumele

Profilul medical

Semntura

Preedintele Comisiei medicale:


(numele, prenumele, semntura)

Chiinu, _____________________2011
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Anex
la Certificatul de sntate
DATELE
examenului medical
Internist___________________________________________________________
__________________________________________________________________
__________________________________________________________________
Chirurg____________________________________________________________
__________________________________________________________________
__________________________________________________________________
neurolog___________________________________________________________
__________________________________________________________________
__________________________________________________________________
psihiatru___________________________________________________________
__________________________________________________________________
__________________________________________________________________
narcolog __________________________________________________________
__________________________________________________________________
__________________________________________________________________
oftalmolog _________________________________________________________
__________________________________________________________________
__________________________________________________________________
otorinolaringolog ____________________________________________________
__________________________________________________________________
__________________________________________________________________

Semntura preedintelui
Comisiei medicale
L..
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