Ministerul Sntii al Republicii Moldova

denumirea instituiei

DOCUMENTAIE MEDICAL
Formular
nr. 086/e

Aprobat de MS al RM
nr. 828 din 31.10.11
PM

ADEVERIN MEDICAL nr. ________

Concluzia medical se completeaz pentru abiturienii instituiilor de nvmnt superior profesional i mediu profesional,
colegiilor i persoanelor la angajarea n serviciu pentru determinarea stabilirea aptitudinii profesionale.
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din ________________________________20___

1. Eliberat ________________________________________________________________________________________

denumirea i adresa instituiei care a eliberat adeverina

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2. Denumirea instituiei de nvmnt, instituiei, organizaiei, unde se prezint adeverina

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3. Numele, prenumele________________________________________________________________________________
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Numr de identificare______________________________________________________________________________

4. Sex

M/F
M/

5. Data naterii ___________________________________________________

6. Adresa la domiciliu: _______________________________________________________________________________

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7. Afeciuni antecedente _____________________________________________________________________________

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8. Datele privind aflarea la eviden, starea sntii n momentul examenului medical, diagnosticul:
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Medicul de familie ________________________________________________________________________________

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9. Vaccinri preventive (a indica data)___________________________________________________________________
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10. Concluzie medical privind aptitudinea profesional ____________________________________________________

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Medicul de familie _________________________________________________________________________________

semntura

Conductorul instituiei de asisten medical primar___________________________________________________

semntura

L..

..

NOT: Concluzia privind aptitudinea profesional se elibereaz de ctre medicul de familie persoanelor n conformitate
cu lista instruciunilor metodice despre selectarea medical, care in a fi admise n instituiile de nvmnt superior
profesional, mediu profesional, colegii i la angajare n serviciu pentru cazurile stabilite de actele normative n vigoare,
cnd pentru aceasta nu sunt stabilite alte forme de adeverine medicale.
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