Unitate Sanitara - SPITAL CLINIC SFANTA MARIA

CAS MB – S0877 Anexa nr.2

Nr. ……… / ……………………

REFERAT MEDICAL
Privind pe dl/dna ……………………………………………… , CNP …………………………...
cu domiciliul in localitatea …………………………………… , str. ……………………………………...
nr. ………… , bl. ……….. , sc. ……….. , et. ……….. , ap. ………… , judet/sector ……………………
Diagnostic clinic :
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Simptomatologie ⃰ ):
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Examen obiectiv detaliat⃰ ): Î =________ cm ; G =________kg ; TA =________mmHg ; AV =________b/m
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Investigatii clinice , paraclinice ⃰ ):
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Tratamente urmate :
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Observatii : …………………………………………………………………………………………………

Medic specialitate,

⃰) Datele inscrise trebuie sa sustina diagnosticul clinic , stadiul evolutiv al afectiuniilor prezentate .
Pentru bolnavii netransportabili , referatul medical trebuie sa contina date care sa justifice din punct de vedere medical imposibilitatea deplasarii .