Изх. № ..............

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МЕДИЦИНСКО УДОСТОВЕРЕНИЕ ЗА ОБЩО ЗДРАВОСЛОВНО СЪСТОЯНИЕ 

/ за ползване на социални услуги в общността или настаняване в специализирана институция и /

Долуподписаният д-р ..........................................................................................................
при ........................................................................................................................................

Издавам настоящото медицинско удостоверение на    
...............................................................................................................................................

/ име, презиме, фамилия/

ЕГН ........................................... адрес:................................................................................

/ област, община, град (село), /ул. №, ж.к., бл., вх., ап./

л.к.№......................... издадена от МВР................. на....................г.

МЕДИЦИНСКА ИСТОРИЯ

ЕР на ТЕЛК №....................../............................
Водеща (основна диагноза по ЕР на 
ТЕЛК) ...........................................................................................
Общи заболявания..............................................................................................................
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І . СОМАТИЧЕН СТАТУС:

1. Пол ..............................
2. Възраст .......................
3. Общо състояние ...................................................................................................

-

подвижност .................................................................................................

4. Съпътствуващи заболявания ...........................................................................
5. Хирургичен статус ...............................................................................................
6. Хранене и диета ..................................................................................................
7. Наличие на алергии.............................................................................................
8. Имунизации и наблюдение.................................................................................

ІІ. НЕВРОЛОГИЧЕН СТАТУС 

1. Сетивност /слух, зрение/......................................................................................

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

2. Мускулен тонус .....................................................................................................
3. Рефлекси ..............................................................................................................
4. Контрол на тазови резервоари ............................................................................

ІІІ. ПСИХИЧЕН СТАТУС

        1. Психомоторика .......................................................................................................

2. Говор .......................................................................................................................
3. Ориентация ............................................................................................................
4. Навици и поведение................................................................................................

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