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FISA MEDICALA De primire in colectivitatile de copii

medicina


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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