Download - Anexa 5
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CMI Dr. _______________
CF: ___________________
Nr. _____/___.___._______
SCRISOARE MEDICALĂ
Către Comisia de Expertiză a Persoanelor cu Handicap
Numele şi prenumele: ______________________________
CNP: _______________________, Vârsta: _______ ani
1. Anamneza ______________________________________________________________
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a. antecedente personale patologice
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2. Diagnosticul medical a. principal
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b. altele
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3. Certificatele medicale actuale (se specifică numărul, data, instituţia
emitentă şi numele medicului care a eliberat certificatul)
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4. Internări în spital (data, instituţia emitentă şi diagnosticul la ieşirea din
spital)
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5. Persoana Persoana se poate / nu se poate deplasa.
Data completării
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Semnătura şi parafa medicului de familie
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