CERTIFICATO MEDICO PER LA CONCESSIONE

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CERTIFICATO MEDICO PER LA CONCESSIONE
DELLA PENSIONE DI INABILITA'
Cognome e nome_____________________________________________
nat _ il _______domiciliat_ a ___________________________________
via _________________________stato civile_______________figli n°__
Documento di riconoscimento n°_______________rilasciato il_________
dal_________________________________________________________
Occupazione attuale___________________________________________
data della cessazione del lavoro________per________________________
Anamnesi remota e prossima: (in particolare evidenza ricoveri ospedalieri)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
E' titolare di rendita-pensione-indennizzi etc.________________________
Specificare tipo e percentuale di invalidità__________________________
____________________________________________________________
____________________________________________________________
Stato generale______________________alt. m _______peso Kg________
cute, annessi e sistema linfoghiandolare (colorito, callosità, dermatosi,
ulcerazioni, edemi, neoformazioni, fistole, cicatrici, sfregi, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
App. cardiovascolare___________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Allegare se possibile le cartelle cliniche relative ai ricoveri stessi
certificato_medico-doc
Polso:_______________Respiro:_______________Press.
Arter.:_________
Vasi:________________________________________________________
____________________________________________________________
____________________________________________________________
App. respiratorio:______________________________________________
____________________________________________________________
____________________________________________________________
App. digerente:______________________________________________
____________________________________________________________
____________________________________________________________
Ernie: (sede, riducibilità, uso di cinti)
____________________________________________________________
____________________________________________________________
Organi ipocondriaci:
____________________________________________________________
____________________________________________________________
App. osteoarticolare: (in particolare evidenza le limitazioni funzionali)___
____________________________________________________________
____________________________________________________________
Articolazioni:_________________________________________________
____________________________________________________________
____________________________________________________________
E' provvisto di apparecchio protesico:
____________________________________________________________
____________________________________________________________
Sistema endocrino:
____________________________________________________________
____________________________________________________________
Sistema nervoso e psiche:
____________________________________________________________
_____________________________________________________
certificato_medico-doc
Occhi e vista:
____________________________________________________________
____________________________________________________________
Orecchio e udito:
____________________________________________________________
____________________________________________________________
App .urogenitale:______________________________________________
____________________________________________________________
Altri organi e apparati:
____________________________________________________________
____________________________________________________________
Documentazioni sanitarie esibite dal dipendente (cartelle cliniche,
accertamenti sanitari, ecc.) ___________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Eventuali terapie praticate:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Diagnosi____________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Per la menomazione complessiva dell'integrità psico-fisica accertata e
riportata in diagnosi, sussistono le condizioni per ritenere che il
dipendente___________________________________________________
____________________________________________________________
____________________________________________________________
SI TROVA NELL'ASSOLUTA E PERMANENTE IMPOSSIBILITA' DI
SVOLGERE QUALSIASI ATTIVITA' LAVORATIVA.
Data_________
Timbro del medico (con indirizzo)
FIRMA MEDICO
___________________________
_______________
certificato_medico-doc
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