Medical Report / Adeverinta Medicala

MEDICAL REPORT / ADEVERINTA MEDICALA

To be completed by the “family physician” or a physician in a clinic in which the applicant has received care for a minimum of 5 years. Please fill in with block letters and well legibly. Formularul poate fi completat doar de medical de familie sau de medicul din clinica/spitalul unde aplicantul primeste ingrijiri medicale de cel putin 5 ani. Completati cu majuscule.

Name of the applicant/Numele aplicantului:
Name of Doctor or Clinic/Numele medicului sau clinicii:
Telephone day/Telefon fix / Mobile/Mobil: / Address/Adresa:
Ti Tick the appropriate box if the applicant suffers or ever suffered from the below/A suferit sau sufera aplicantul de urmatoarele:
□ □ tuberculosis/tuberculoza □ migraine/migrene □ diabetes/diabet
□ □ asthma/astm □ rheumatic fever/febra reumatica □ hepatitis/hepatita (A,B,C)
□ □ depression/depresie □ anorexia/anorexie □ bulimia
□ □ HIV □ epilepsy/epilepsie □ malaria/malarie
□ RPR/Syphilis □ A (H1N1)
If you have answered YES to any of the above give details including dates as applicable/Daca ati raspuns cu DA la vreunul din cele sus enumarate, va rugam sa detaliati (inclusiv data):
Does the applicant suffer from any allergies?/Sufera aplicantul de alergii din cele jos mentionate:
□ □ penicillin/penicilina □ other drugs/alte medicamente □ animals/animale
□ □ food addititves/aditivi □ insect stings/intepaturi de insecte □ other/alte
If you have answered YES to any of the above give full details / Daca ati raspuns cu DA la vreunul din cele sus enumarate, va rugam sa detaliati:
Yes/DA / NO/NU
Is her/his physical activity restricted in any way?/Activitatea fizica este restrictionata in vreun fel?
Is the applicant currently taking any medications?/Este aplicantul in prezent sub tratament medical?
Does the applicant have any cronic or recurring illness?/Sufera aplicantul de boli cronice?
If you have answered YES to any of the above give full details / Daca ati raspuns cu DA la vreunul din cele sus enumarate, va rugam sa detaliati:
How would you describe the applicant’s general state of health?/Cum ati descrie starea generala de sanatate a a aplicantului:
□ □ excellent/excelent □ good/bun □ satisfactory/satisfacator □ poor/slaba

Signature&Stamp/Semnatura si stampila ______Date/Data: ______