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FISA PERSONALA A PACIENTULUI NR. ______ DATA: ____ / ____ / ______; NUME: _____________________________ PRENUME: _________________________ Data nasterii: an: _______ luna: ___ ziua: ___ Domiciliul: - Localitatea: ______________________________ jud: _________________; Str: _________________________ Nr:____ Bl: _____ Sc: _____ Et: ____ Ap: ______; email:____________________________________@_________________________ * Grup sangvin: ………. ; Rh: [NEGATIV] / [POZITIV] Greutate: ……………. ; Inaltime: …………………; Alergii cunoscute la: ………………………………………………………………………………………………………………………; Ocupatia: …………………………………………………………………………………………………………………………………………; ** Diagnosticul de trimitere: ………………………………………………………………………………………………………………. Cine trimite: ……………………………………………………………………………………………………………………………………; Diagnostic principal: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………..; Boli concomitente: …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………..; *** SEMNE SI SIMPTOME SUBIECTIVE [descrise de pacient]: 1 SOCIETATEA ROMANA DE YUMEIHO®

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Page 1: FISA PACIENTULUI

FISA PERSONALA A PACIENTULUI

NR. ______

DATA: ____ / ____ / ______;

NUME: _____________________________ PRENUME: _________________________

Data nasterii: an: _______ luna: ___ ziua: ___

Domiciliul: - Localitatea: ______________________________ jud: _________________;

Str: _________________________ Nr:____ Bl: _____ Sc: _____ Et: ____ Ap: ______;

email:____________________________________@_________________________

*

Grup sangvin: ………. ; Rh: [NEGATIV] / [POZITIV]

Greutate: ……………. ; Inaltime: …………………;

Alergii cunoscute la: ………………………………………………………………………………………………………………………;

Ocupatia: …………………………………………………………………………………………………………………………………………;

**

Diagnosticul de trimitere: ……………………………………………………………………………………………………………….

Cine trimite: ……………………………………………………………………………………………………………………………………;

Diagnostic principal: ……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………..;

Boli concomitente: ……………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………..;

***

SEMNE SI SIMPTOME SUBIECTIVE [descrise de pacient]:

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………..………;

1SOCIETATEA ROMANA DE YUMEIHO®

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ANTECEDENTE HEREDOCOLATERALE:

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………..;

ANTECEDENTE PERSONALE [boli cronice cunoscute, interventii chirurgicale, traumatisme/accidente, boli

infecto-contagioase, boli/tulburari psihice, respectiv suferinte: neurologice / respiratorii / musculo scheletale –

osoase, articulare, musculare - / cardiovasculare / endocrine / imunologice / urologice / ginecologice / alergice /

digestive –stomac, intestin, ficat, vezica biliara, etc - / alte suferinte semnificative] :

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

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****

CONDITII DE VIATA SI MUNCA:

POTENTIAL PATOGEN LOC MUNCA :

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………;

POTENTIAL PATOGEN DOMICILIU:

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………;

CONDITII SOCIO-FAMILIALE:

……………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………....;

ALTE OBSERVATII PRIVIND FACTORII DE MEDIU:

2SOCIETATEA ROMANA DE YUMEIHO®

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……………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………;

*****

ISTORICUL PATOLOGIEI PREZENTE [DEBUT – EVOLUTIE- PARTICULARITATI]:

..................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

....................................................................................................................................................................................... ;

TRATAMENTE

ANTERIOARE: ......................................................................................................................................................................... ..............................

..................................................................................................................................................................................................................................

............................................................................................................................................................................................. ;

EVOLUTIE: ........................................................................................................................................................................................................ .....

...................................................................................................................................................................................................................... ;

******

STAREA PREZENTA:

CARACTERISTICA DURERII:

- Conditii de aparitie: repaus / efort / miscare / pozitie / ............................................................................................;

- Localizare: ........................................................................................................................................................................................ ;

- Intensitatea durerii: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 ;

- caracterul durerii: [difuza, lancinanta, surda, pulsatila, nevralgie, etc.]

................................................................................................................................................................................................................. ;

- Redoare matinala: DA / NU ; - Limitarea mobilitatii: mare / medie / mica ;

- Evolutie in timp: constanta / recurenta in pusee / alta: ................................................................................................................. ;

- Durata: ........ secunde / ........ minute /........ ore / ........ zile / ........ luni / ........ ani;

- Factori favorizanti: ...................................................................................................................................................................... ;

- Factori agravanti: ...................................................................................................................................................................... ;

- Calmare la: ...................................................................................................................................................................................... ;

- Alte observatii: ............................................................................................................................................................................... ;

TULBURARI NEUROLOGICE:

- Epilepsie: da / nu; frecventa crize: zilnice / lunare /anuale;

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- Parestezii:.............................................................................................................................................................................................. ;

- Pareze: faciale / hemipareze [ stg /dr ] / parapareze / tetrapareze / ; spastice / flasce / altele:

..................................................................................................................................................................................................................... ;

- Paralizii: paraplegie: da / nu; hemiplegie: stg / dr; monoplegie: m. Inf. stg / dr. – m. Sup. stg / dr.

Obs: ......................................................................................................................................................................................................... ;

- Nevralgii: ............................................................................................................................................................................................... ;

- Altele: ............................................................................................................................................................................................... ;

STAREA MUSCULARA GENERALA:

- Troficitate: ............................................................................................................................................................................................ ;

- Tonicitate: ............................................................................................................................................................................................. ;

- Kinezie: .................................................................................................................................................................................................. ;

- Alte obs: ................................................................................................................................................................................................ ;

TEGUMENTE SI MUCOASE

[aspect - culoare, elasticitate, umiditate, boli dermatologice,particularitati, etc.]:

- Hiperhidroza: da / nu; palmara / plantara / axilara / genitala / generalizata;

- Veruci – negi: da / nu; Psoriasis: da / nu; Pitiriasis: da / nu; Impetigo: da / nu; Micoze: da / nu;

Altele:....................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

............................................................................................................................................................................................................................... ;

SISTEM GANGLIONAR SUPERFICIAL [PREZENTA GANGLIONI MARITI DA / NU; LOCALIZARE]: ...........................................................................................................................................................................................................................

.......................................................................................................................................................................................................................... ;

APARAT CARDIO-VASCULAR:

- Tensiunea arteriala: ___ / ___ ; Frecventa cardiaca [ Puls ]: ____ / min; Ritm: regulat / neregulat;

- Boli coronare: anghina pectorala: da / nu; stent: da / nu; altele: ................................................................................. ;

- Tulburari de ritm cardiac: pacemaker: da / nu; tahicardii da / nu; bradicardii da / nu; exstrasistole

ventriculare/atriale: da / nu; fibrilatii atriale/ventriculare: da / nu; altele: ..................................................................... ;

- Cardio-miopatii: insuficienta cardiaca: da / nu; altele: ......................................................................................................... ;

- defecte valvulare [valvulopatii] si septale: insuficienta mitrala: da / nu; altele: ..........................................................;

- Arterita: da / nu; Varice: da / nu; Trombo-flebita: da / nu; Localizare varice: .............................................................;

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- Tulburari de coagulare a sangelui: tratament cu anticoagulante: da / nu; hemofilie: da / nu;

Alte boli sangvine: ............................................................................................................................................................................ ;

- Alte observatii: .................................................................................................................................................................................... ;

APARAT RESPIRATOR:

- TBC: da / nu; Bronsita cronica obstructiva: da / nu; Emfizem pulmonar: da / nu; Pneumonie: da / nu;

Bronsita acuta/cronica: da / nu; Altele: ............................................................................................................................................... ;

- Frecventa respiratorie: rara / medie / tahipnee; Obs: ..................................................................................................... ;

- Amplitudinea respiratorie: mica /medie /mare; Obs: ....................................................................................................... ;

- Tip dominant respiratie: abdominala - diafragmatica / toracala-medie / toracala-superioara;

APARAT DIGESTIV SI BOLI METABOLICE:

- Obezitate: da / nu; [tip: 1, 2, 3]; indicele de masa corporala: ............; obs:..................................................................... ;

- Astenie/casexie: da / nu; anorexie: da / nu; obs:.................................................................................................................... ;

- Esofagita /de reflux: da / nu; ulcer gastric/duodenal: da / nu; gastrita hipo/hiperacida: da / nu; colita: da / nu;

duodenita: da / nu; enterita: da / nu; hemoroizi: da / nu; altele: ................................................................................................... ;

- Hepatita tip A / B / C / D : da / nu; alta: [etilica, toxica, etc.] da / nu;.................................................................................;

- Diskinezie biliara: da / nu; Litiaza biliara: da / nu; Colecistita acuta: da / nu; Colecistectomie: da / nu;

alta suferinta biliara: ......................................................................................................................................................................... ;

- Pancreatita cronica: da / nu; Alte suferinte pancreatice: da / nu; .....................................................................................;

- Diabet zaharat: da / nu: tip: ................................................... complicatii: ..................................................................................... ;

- Scaun: diaree/constipatie: da / nu; obs:..................................................................................................................................... ;

- Sindrom dis/metabolic: da / nu; obs: .......................................................................................................................................... ;

- Guta [reumatism metabolic]: da / nu; localizare tof: ............................................................................................................... ;

- Apendic-ectomie: da / nu;

- Altele: ..................................................................................................................................................................................................... ;

BOLI ENDOCRINE:

- Disfunctii tiroidiene: hipo/hipertiroidie: da / nu; Noduli tiroidieni: da / nu; obs: ............................................................;

- Paratiroide: obs: ............................................................................................................................................................................... ;

- Glande Suprarenale: obs: ............................................................................................................................................................. ;

- Ovare / Testicule: obs: ................................................................................................................................................................... ;

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- Hipofiza: obs: ..................................................................................................................................................................................... ;

- Pancreas endocrin: : ....................................................................................................................................................................... ;

- Altele: .................................................................................................................................................................................................... ;

APARAT GENITO-URINAR:

- Litiaza renala: da / nu; Infectii renale/vezicale: da / nu; pielonefrita: da / nu; glomerulonefrita: da / nu;

Alte suferinte renale/vezicale/uretra/uretere: ............................................................................................................................. ;

- Adenom de prostata: da / nu; obs: .............................................................................................................................................. ;

- Fibrom uterin: da / nu; obs: ............................................................................................................................................................ ;

- Chisturi ovariene: da / nu; obs: ..................................................................................................................................................... ;

- Histerectomie: da / nu; obs: ........................................................................................................................................................... ;

- Alte suferinte ginecologice: ............................................................................................................................................................ ;

APARATUL LOCOMOTOR

COLOANA VERTEBRALA:

- TIPUL CONSTITUTIONAL AL CV: SPATE DREPT [PLAT] / ROTUND / SCOBIT SI ROTUND / NORMAL;

- CIFOZA / SCOLIOZA / HIPERLORDOZA: DA/NU;

- LOCALIZARE: CERVICAL / TORACAL / LOMBAR;

OBS: ....................................................................................;

- GRAD: ............................................................................................................................................................................. ;

- OBSERVATII: ................................................................................................................................................................ ;

- PATOLOGIE DISCALA: DA / NU;

- LOCALIZARE: ................................................................................................................................................................ ;

- TIP: HERNIE / TASARE/ ALTA: ............................................................................................................................ ;

- SEMIOLOGIE CLINICA: PAREZE, PARESTEZII, ALGII, REDORI/CONTRACTURI MUSCULARE,

ALTELE: ............................................................................................................................................................................ ;

- OBSERVATII: ................................................................................................................................................................ ;

- ARTROZA VERTEBRALA [ SPONDILOZA/SPONDILODISCARTROZA/ETC.]: DA / NU;

- OBSERVATII: ................................................................................................................................................................ ;

- ALTE OBSERVATII PRIVIND STAREA C.V. :

........................................................................................................................................................................................................................

........................................................................................................................................................................................................................

........................................................................................................................................................................................................................

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........................................................................................................................................................................................................................

....................................................................................................................................................................................................................... ;

EXAMENUL BAZINULUI:

- BAZIN SIMETRIC: DA / NU; OBS: ............................................................................................................................................... ;

- ARTICULATIILE SACRO-ILIACE:

- DISLOCARE COXALA PREZENTA: DA / NU;

- TIPUL DISLOCARII COXALE: DREAPTA / STANGA / MIXTA ; AMPLITUDINEA: .............. CM

- MOBILITATE ARTICULATIE SACRO-ILIACA STANGA: DA / NU / LIMITATA;

- MOBILITATE ARTICULATIE SACRO-ILIACA DREAPTA: DA / NU / LIMITATA;

- SACRO-ILEITA: DA / NU;

- OBSERVATII: ................................................................................................................................................................................. ;

- ARTICULATIILE COXOFEMURALE:

- COXA VARA/VALGA: DA / NU; OBS:.................................................................................................................................. ;

- MOBILITATE ART. COXOFEMURALA STANGA: NORMALA / MEDIE / REDUSA / LAXITATE;

- MOBILITATE ART. COXOFEMURALA DREAPTA: NORMALA / MEDIE / REDUSA / LAXITATE;

- EXTENSIE / FLEXIE; ADDUCTIE / ABDUCTIE; ROTATIE; ALTA:

................................................................................................................................................................................................................ ;

- ARTROZA COXALA [COXARTROZA]: DA / NU; LOCALIZARE: DREAPTA / STANGA / BILATERALA;

- PROTEZARE ARTICULARA SOLD: DA / NU;

- OBSERVATII: ................................................................................................................................................................................. ;

EXAMENUL MEMBRELOR INFERIOARE:

- OBSERVATII PRIVIND VASCULARIZAREA: ................................................................................................................................... ;

- VARICOZITATI: DA / NU; DIMENSIUNE: MICI / MEDII / MARI; COMPLICATII: FLEBITE /

TROMBOFLEBITE / ULCER VARICOS / ALTELE: ........................................................................................................................... ;

LA MEMBRUL INFERIOR: STANG / DREPT / AMBELE;

- ARTERITA / ARTERIOPATIE OBLITERANTA: DA / NU; OBS: .................................................................................;

LA MEMBRUL INFERIOR: STANG / DREPT / AMBELE;

- OBSERVATII: ................................................................................................................................................................................. ;

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- OBSERVATII PRIVIND STAREA

MUSCULATURII: ........................................................................................................................ ;

- M. INF. STANG - TONUS: NORMAL / HIPOTONIE / HIPERTONIE; GAMBA / COAPSA;

- M. INF. DREPT - TONUS: NORMAL / HIPOTONIE / HIPERTONIE; GAMBA / COAPSA;

- OBSERVATII PRIVIND LUNGIMEA MEMBRELOR INFERIOARE:

- M. INF. STANG: EGAL / MAI SCURT / MAI LUNG COMPARATIV CU DREPTUL CU: ................. CM ;

- OBSERVATII: ................................................................................................................................................................................. ;

- OBSERVATII PRIVIND STAREA ARTICULATIILOR:

- GENUNCHI:

- LIMITARE MOBILITATE GENUNCHI: DA / NU; STG / DR; FLEXIE / EXTENSIE;

- GENU VALGUM / VARUM: DA / NU; OBS. ................................................................................................ .;

- ARTROZA [ GONARTROZA]: DA / NU; STANG / DREPT;

- LEZIUNI MENISC: DA / NU; STANG / DREPT; INTERN / EXTERN; INTERVENTIE

CHIRURGICALA: DA / NU; OBS. ...................................................................................................................................................... .;

- LEZIUNI LIGAMENTARE: DA / NU; STANG / DREPT; INTERNE / EXTERNE; INCRUCISAT

ANTERIOR/POSTERIOR; INTERVENTIE CHIRURGICALA DE RECONSTRUCTIE: DA / NU;

- BURSITA: DA / NU; OBS. ................................................................................................................................. .;

- OBSERVATII: ................................................................................................................................................................................. ;

ARTICULATIILE TARSULUI [GLEZNA], METATARSIENE SI FALANGELE PICIORULUI:

- PLATFUS: DA / NU; GRAD: 1, 2, 3; OBS. ............................................................................................................................ .;

- PICIOR CAVUS: DA / NU; OBS. ............................................................................................................................................... .;

- HALLUX VALGUS: DA / NU: STG / DR / BILATERAL; OBS. ..........................................................................................;

- ARTROZA: DA / NU; OBS. ........................................................................................................................................................... .;

- LUXATII / ENTORSE – FRECVENTE / RARE / UNICE; - STG / DR / BILATERAL; ...............................................;

- PINTENI CALCANEENI: DA / NU; STG / DR / BILATERAL; OBS. ................................................................................;

- INTERVENTII CHIRURGICALE: DA / NU; - TIP: OBS. ...................................................................................................... .;

- OBSERVATII: ...................................................................................................................................................................................... ;

- FRACTURI: .......................................................................................................................................................................................... ;

TROFISM: OBS. .................................................................................................................................................................................. .;

- ONICOMICOZA: DA / NU; MICOZA INTERDIGITALA: DA / NU; EXTINSA/REDUSA; STG/DR/BILATERAL;

- ALTE OBSERVATII PRIVIND STAREA MEMBRELOR INFERIOARE:

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........................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

.................................................................................................................................................................................................................................

;

EXAMENUL MEMBRELOR SUPERIOARE:

- FRACTURI: HUMERUS: DA / NU; RADIUS: DA / NU; ULNA [OLECRAN] DA / NU; CARPIENE: DA / NU;

METACARPIENE: DA / NU; (1,2,3,4,5) FALANGE: DA / NU; PROXIMALE / MEDIALE / DISTALE (1,2,3,4,5)

OBS: .................................................................................................................................................................................................................... ;

- OBSERVATII PRIVIND VASCULARIZAREA: EVIDENTIERE SISTEM VENOS SUPERFICIAL: DA / NU;

SINDROM RAYNAUD: DA / NU; ALTE OBS: ...................................................................................................................................... ;

- OBSERVATII PRIVIND STAREA MUSCULATURII: .................................................................................................................... ;

- M. SUP. STANG - TONUS: NORMAL / HIPOTONIE / HIPERTONIE; BRAT / ANTEBRAT;

- M. SUP. DREPT - TONUS: NORMAL / HIPOTONIE / HIPERTONIE; BRAT / ANTEBRAT;

- VOLUM MUSCULAR SIMETRIC STG / DR: DA / NU; DIMINUAT: STG / DR;

- OBSERVATII PRIVIND STAREA ARTICULATIILOR:

- UMAR: - LUXATII / ENTORSE / TRAUMATISME; UMAR: STG / DR ;

- VECHIME: ....................; GRAD: ...........................; OBS: ....................................................................................;

- LIMITARE MOBILITATE UMAR: STG / DR; EXTENSIE / FLEXIE; ADDUCTIE / ABDUCTIE;

ROTATIE; ALTA: ........................................................................................................................................................... ;

- ARTRITA: - PERIARTRITA SCAPULO-HUMERALA: DA / NU; TENDINITA, BURSITA: DA / NU;

- ARTROZA: DA / NU; ................................................................................................................................................. ;

- OBSERVATII: ............................................................................................................................................................... ;

- COT: - LUXATII / ENTORSE / TRAUMATISME; COT: STG / DR ;

- VECHIME: ....................; GRAD: ...........................; OBS: ....................................................................................;

- ARTRITA: DA / NU; STG / DR;

- BURSITA: DA / NU; EPICONDILITA: DA / NU; STG / DR; ALTELE: ......................................................;

- ARTROZA: DA / NU; STG / DR; ............................................................................................................................ ;

- LIMITARE MOBILITATE COT: STG / DR; FLEXIE / EXTENSIE; GRAD: ........................................... ;

- ALTE OBS. .................................................................................................................................................................... .;

- ARTICULATIA MAINII: - LUXATII / ENTORSE / TRAUMATISME; STG / DR ;

- VECHIME: ....................; GRAD: ...........................; OBS: ....................................................................................;

- ARTRITA: DA / NU; STG / DR;

- BURSITA: DA / NU; STG / DR; SINDROM TUNEL CARPIAN: DA / NU; STG / DR ;

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- ALTELE: .......................................................................................................................................................................... ;

- ARTROZA: DA / NU; STG / DR; ............................................................................................................................ ;

- LIMITARE MOBILITATE: STG / DR; FLEXIE / EXTENSIE; GRAD: ...................................................... ;

- ALTE OBS. .................................................................................................................................................................... .;

- ARTICULATIILE DEGETELOR MAINII: - LUXATII / ENTORSE / TRAUMATISME; STG / DR ;

- ARTRITA: DA / NU; ARTROZA: DA / NU; ALTE LEZIUNI: DA / NU; TIP: ............................................;

- ALTE OBS. .................................................................................................................................................................... .;

TORACE:

- Particularitati cutie toracica: naviculara [in carena]: da / nu; infundata: da / nu;

- Fracturi costale: da / nu; Coasta/ele nr. ....................... stg / dr; ............................................................................................. ;

- Fracturi stern: da / nu; ....................................................................................................................................................................... ;

- interventii chirurgicale: cord deschis: da /nu; plaman: da /nu; altele: ..............................................................................;

- nevralgii intercostale: da /nu; la nivelul: ...................................................................................................................................... ;

- coaste supranumerare [cervicale]: da / nu; ............................................................................................................................... ;

- ALTE OBS. .......................................................................................................................................................................................... .;

ALTE OBSERVATII PRIVIND APARATUL LOCOMOTOR:

........................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................

............................................................................................................................................................................................................................... ;

BOLI REUMATISMALE / DEGENERATIVE:

- POLIARTRITA REUMATOIDA: DA / NU; REUMATISM ARTICULAR ACUT: DA / NU; SPONDILITA

ANCHILOPOIETICA: DA / NU; SINDROM REITER: DA / NU; REUMATISM PSORIAZIC: DA / NU;

- ALTELE: .............................................................................................................................................................................................. .;

OBSERVATII PRIVIND ORGANELE DE SIMT:

- VAZ: PATOLOGIE A OCHIULUI DR / STG: MIOPIE / HIPERMETROPIE / ASTIGMATISM / GLAUCOM/

PREZBITISM, ALTA: .................................................................................................................................................................................... .;

- AUZ: URECHE STG / DR; HIPOACUZIE / OTITE – FRECVENTE,RARE - / TULBURARI LABIRINTICE:

- ACUFENE / TINITUS: DA / NU; VERTIJ: DA / NU; OTOSCLEROZA: DA / NU;

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ALTE AFECTIUNI : ............................................................................................................................................................................. .;

- TULBURARI OLFACTIVE: ............................................................................................................................................................. .;

- SINUSITA: DA / NU [RARE / FRECVENTE], [SINUS FRONTAL / MAXILAR], OBS. ....................................... ;

- RINITA ALERGICA: DA / NU; OBS. .................................................................................................................................... .;

- DEVIATIE SEPT NAZAL: DA / NU; OBS. ......................................................................................................................... .;

- ALTE AFECTIUNI : .................................................................................................................................................................... .;

- TULBURARI DE GUST: ................................................................................................................................................................. .;

- TULBURARI TACTILE: DESENSIBILIZARE: STG / DR; OBS. ..................................................................................... ;

- ALTE OBS: .......................................................................................................................................................................................... .;

BOLI SI TULBURARI PSIHICE:

- SINDROM ANXIOS: DA / NU; LABILITATE PSIHICA: DA / NU; NEURASTENIE: DA / NU;

SCHIZOFRENIE/PARANOIA: DA / NU; SINDROM DEPRESIV: DA / NU; TENTATIVE SUICID: DA / NU;

ALTELE: ..............................................................................................................................................................................................................

..................................................................................................................................................................................................................................

................. ;

REZULTATELE INVESTIGATIILOR SI ALE CONTROALELOR INTERDICIPLINARE:

- IMAGISTICA [RMN, CT, ROENTGEN, ENDOSCOPIE, ECOGRAFIE,ALTELE]:

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- LABORATOR [IMUNOLOGICE, ELEMENTE FIGURATE SANGVINE, ENZIME, ALERGOLOGIE, ETC]

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- EXPLORARI FUNCTIONALE:

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- ALTE INVESTIGATII:

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