(Stamp) GYMNASIUM NO.

56
Health care facility SECTOR 2 BUCHAREST
DOCTOR'S OFFICE
(name, address, phone).....................................................

File no./Registration no. 95

File release date: ..................
Examination date: 2017-01

Medical certificate for enrolment in community

Name and surname: Negoi Maria, gender F, age 14,2,

Address: Street......................,no. ...., city............, county/sector............
Institution for enrolment:................................
Name and surname of parent/legal guardian:............................Contact number: ....................

Medical history NO YES :

-asthma
-hyperactivity disorder
-chronic otitis media /recurrent
-congenital hip disorders
-learning / development impairment
-diabetes mellitus
-osteoarticular lesions
-convulsions
-speech/hearing/visual impairment
-tuberculosis
-other
*(if you checked at least one of these, please attach the relevant medical files)
Allergies NO YES :
-drugs:................
-foods:................
-other:.................
Chronic conditions medication NOYES (list)
Vaccines (see epidemiologic certificate - immunization record)
Medical examination
Height 165 cm; weight 65 kg; BMI 23.9 kg/m2
BP (for children >3 years) 140/90 mmHg
Routine physical (normal, abnormal)
ENT............................
Normal dentition YES NO:.............................
Cephalic extremity - cervical region:.......................
Normal lymph nodes YES NO:........................

Recommendations
Normal physical activity YES NO restrictions (if necessary):.............................
Diverse diet YES NO restrictions:.............................
Reassessment is necessary NO YESfor................scheduled date_ _/_ _/_ _

Normal Pulmonary YES NO:..................................

Normal Cardiovascular YES NO:...........................
Normal Abdominal YES NO:...................................
Normal Genitourinary YES NO:..............................
Normal extremities YES NO:..................................
Normal integument YES NO:..................................
Normal psychological development YES NO:........
Normal speech YES NO:........................................
Normal behavior YES NO:......................................

Development (preschoolers)
Within normal limits YES NO:..................................
If you checked no, state the type of impairment:
-cognitive...............................................
-communication/speech........................
-emotional/social....................................
-adaptation.............................................
-motricity................................................

Hearing
Audiometry (if necessary)
normal
abnormal
Sight
Visual acuity normal YESNO
Left eye:.................
Right eye:...............
Corrective lenses YESNO
Strabismus NOYES
Additional examinations NOYES which:.......
Requires special education
Others....................

Assessment results
Child apt/inaptfor enrolment in community
Observations...........

Doctor, doctor's seal and signature DR. LIANA MAN

general medicine
code
(handwriting)Landline: 624.13.79
Mobile phone: 0722/793030
0723/751843

MEDICAL CERTIFICATE

NAME AND SURNAME: Negoi Maria

DATE OF BIRTH: 2002-11-08
ADDRESS: 243 Pantelimon Avenue, Block no. 52, Entrance D, app. no. 15
VACCINES: BCG: 2002-11-11
DPT: 2003-1-14; 2003-3-18; 2003-5-20; RI - 2003-11-11; RII - 2005-5-4
aP: 2003-1-14; 2003-3-18; 2003-5-20; RI - 2003-11-11
HepB: HBI 2002-11-08; HBII 2003-1-14; HBIII 2003-5-20
MRV: Priorix 2004-1-14
MOTHER-- TB - No
FATHER-- TB - No

PERSONAL MEDICAL HISTORY: weight at birth 2750 lenght 50

measles (yes/no), epidemic hepatitis (yes,no), pertussis
(yes, no), epidemic parotitis (yes, no)
Febrile convulsions at 2 years 6 months. They have not reoccured.
Clinically healthy.
EPIDEMIOLOGIC CERTIFICATE
Clinically healthy. Does not have infecto-contagious diseases.
Can be enrolled in a community.

(Doctor's seal and signature)

DR. VICTORIA COJOCARU
Family physician
PRIVATE MEDICAL PRACTICE
SECTOR 2 BUCHAREST

DR. VICTORIA COJOCARU

consultant pediatrician
family physician
code 362204

(handwriting) 2007-09-14
Clinically healthy.
Apt for community
Dr. Cojocaru