بسمهتعالي |
بهزيستي استان.......................... |
بهزيستي شهرستان............................. |
1ـ مشخصات فردي: |
نام: نام خانوادگي: نام پدر: شماره شناسنامه: |
محل تولد: شغل: تحصيلات: |
آدرس محل سكونت: |
|
|
2ـ تاريخچه و شرح حال پزشكي (بصورت مختصر): |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
|
|
3ـ خلاصه مدارك و مستندات: |
1ـ ........................................................................................................................................................................................................ |
2ـ ........................................................................................................................................................................................................ |
3ـ ........................................................................................................................................................................................................ |
4ـ ........................................................................................................................................................................................................ |
5 ـ ...................................................................................................................................................................................................... |
6 ـ ....................................................................................................................................................................................................... |
|
|
4ـ اظهارنظر كميسيون پزشكي: |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
................................................................................................................................................................................................................ |
نوع معلوليت: شدت معلوليت: |
|
|
5 ـ تأييد اعضاء كميسيون پزشكي: |
اسامي اعضاء محل امضاء |
اسامي اعضاء محل امضاء |
1ـ ....................................................... .......................................... |
6 ـ ...................................................... .......................................... |
2ـ ....................................................... .......................................... |
7ـ ....................................................... .......................................... |
3ـ ....................................................... .......................................... |
8 ـ ...................................................... .......................................... |
4ـ ....................................................... .......................................... |
9ـ ....................................................... .......................................... |
5 ـ ...................................................... .......................................... |
10ـ .................................................... .......................................... |
|
|
معاون توانبخشي استان مديركل استان |