Unitatea sanitara_______________ 343t197d _______________ 343t197d _______________ 343t197d _______
Sector_______________ 343t197d _______________ 343t197d _______________ 343t197d _______________ 343t197d _
FISA MEDICALA
De primire in colectivitatile de copii
Numele si prenumele copilului_______________ 343t197d _______________ 343t197d _______________ 343t197d __
Data nasterii_______________ 343t197d _______________ 343t197d _______________ 343t197d _______________ 343t197d _
Domiciliul_______________ 343t197d _______________ 343t197d _______________ 343t197d _______________ 343t197d ___
Antecedente fiziologice:
Nascut la _______________ 343t197d _______________ 343t197d _______________ 343t197d _____________
Greutate_______________ 343t197d _______________ 343t197d _______________ 343t197d ______________
Inaltimea_______________ 343t197d _______________ 343t197d _______________ 343t197d _____________
Eventualele deficiente sau malformatii_______________ 343t197d _______________ 343t197d _____
Dezvoltare somato-psihica_______________ 343t197d _______________ 343t197d ______________
Boli :
Rujeola : DA/NU
Dizenterie : DA/NU
Scarlatina : DA/NU
Tuse Convulsiva : DA/NU
Reumatism: DA/NU
Crize comitiale : DA/NU
Alte Boli :_______________ 343t197d _______________ 343t197d _______________ 343t197d ____________
Antecedente heredo-colaterale:
Mama : TBC: DA/NU Lues : DA/NU
Tata : TBC: DA/NU Lues :DA/NU
Data efectuarii imunizarilor:
BCG :_______________ 343t197d _______________ 343t197d _______________ 343t197d _______________ 343t197d DTP: I ____________-II_______________ 343t197d __III__________Rapel____________
AP: I____________II_______________ 343t197d __III_____________Rapel___________
DT:_______________ 343t197d _______________ 343t197d ______Revaccinari_______________ 343t197d __
HB:_______________ 343t197d _______________ 343t197d Revaccinari_______________ 343t197d ________
Antirujeolic:_______________ 343t197d _____________Revaccinari_______________ 343t197d ___
Antigripal:_______________ 343t197d _______________ 343t197d _____Revaccinari:____________
Testari biologice:
IDR: data _______________ 343t197d _______________ 343t197d __rezultat_______________ 343t197d ____
Alte examene :
Coprocultura : data_______________ 343t197d _________rezultat_______________ 343t197d _____
Coproparazitologic : data_______________ 343t197d ______rezultat_______________ 343t197d ___
Exudat faringian:data_______________ 343t197d _______rezultat_______________ 343t197d _____
Aviz epidemiologic :
Clinic Sanatos : DA/NU
Poate frecventa colectivitatea : DA/NU
Data : MEDIC DE FAMILIE
Semnatura si parafa medicului
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