referat medic specialist afectiuni neurologice.doc

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JUDETUL_________________________________ LOCALITATEA ___________________________ NR._____/______ UNITATEA SANITARA.____________________ REFERAT MEDIC SPECIALIST - pentru afectiuni neurologice - Privind situatia d-nei/d- lui_____________________________________ posesor al B.I./C.I. seria __________ nr. ______ CNP ______________ domiciliat(a) in localitatea ____________________str./sat___________ nr.________ bloc ______scara _______ap._____ 1 .Nr.fisa dispensarizare __________________ data intocmirii ________ 2.Antecedente privind afectiunea ( se va preciza etiologia – in pareze / plegii ) _________________________________________________ __________ _________________________________________________ _________________________________________________ ____________________ 3.Debutul si evolutia bolii _________________________________________________ __________ _________________________________________________ _________________________________________________ ____________________ 4.Vechimea bolii _________________________________________________

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Page 1: referat medic specialist afectiuni neurologice.doc

JUDETUL_________________________________LOCALITATEA ___________________________ NR._____/______UNITATEA SANITARA.____________________

REFERAT MEDIC SPECIALIST- pentru afectiuni neurologice -

Privind situatia d-nei/d-lui_____________________________________posesor al B.I./C.I. seria __________ nr. ______ CNP ______________domiciliat(a) in localitatea ____________________str./sat___________nr.________ bloc ______scara _______ap._____

1 .Nr.fisa dispensarizare __________________ data intocmirii ________

2.Antecedente privind afectiunea ( se va preciza etiologia – in pareze / plegii ) _________________________________________________________________________________________________________________________________________________________________________________

3.Debutul si evolutia bolii _________________________________________________________________________________________________________________________________________________________________________________

4.Vechimea bolii _________________________________________________________________________________________________________________________________________________________________________________

5.1nternarea in spital _____________________________________________________________________________________________________________________

6.Examenul clinic (subiectiv,obiectiv, functional) ______________________________________________________________________________________________________________________

Statiunea si mersul

Coordonare motorie

Page 2: referat medic specialist afectiuni neurologice.doc

Tonus muscular

Motilitate involuntara

Motilitatea voluntara (FM si MAS )

Mb. sup.

Mb. Inf

Sensibilitate

Reflexe

Vorbire, deglutitie

Sistem nervos vegetativ

Semne neurologice particulare

7.Diagnostic clinic _________________________________________________________________________________________________________________________________________________________________________________

8.Dependent sau partial dependent de alta persoana ______________________________________________________________________________________________________________________

9.Deplasabila sau nedeplasabila ______________________________________________________________________________________________________________________

10. Plan de recuperare _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Data completarii _____________________________________________Nr. Fisei de consultatii/Nr. Foii de observatie _____________________

Nume, semnatura si parafa medicului

Page 3: referat medic specialist afectiuni neurologice.doc