REPÚBLICA DE MOÇAMBIQUE

MINISTÉRIO DE SAÚDE
SERVIÇO NACIONAL DE SAÚDE
RELATÓRIO MÉDICO PARA AS JUNTAS DE SAÚDE

1. DADOS DO DOENTE

NOME DO DOENTE____________________________________________________________
ENDEREÇO ___________________________________________________________________
IDADE______ SEXO__________________________RAÇA ____________________________
UNIDADE SANITÁRIA_______________________________________ NID ______________
TEMPO DE SERVIÇO PRESTADO AO ESTADO _____________________________ (ou)
TEMPO DE SERVIÇO PRESTADO A EMPRESA OU SERVIÇOS ____________ DURANTE
QUANTO TEMPO DESCONTOU PARA O I.N.S.S ___________________________________

2. RESUMO DA HISTÓRIA CLINICA E EXAME OBJETIVO

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3. RESULTADOS DOS MEIOS AUXILIARES DE DIAGNOSTICO EFETUADOS

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Modelo: SIH-18 - MISAU

Computer Shop, LDA.

4. CONCLUSÃO DO DIAGNÓSTICO
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5. TERAPÊUTICA INSTITUÍDA
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6. EVOLUÇÃO E PROGNÓSTICO
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7. CONCLUSÕES
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8. RAZÕES DO ENVIO DO DOENTE Á JUNTA

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Nota: É obrigatório o preenchimento de todos itens.

O CLINICO ASSISTENTE CARIMBO DO SERVIÇO

Nome completo em letra de imprensa do chefe dos serviços

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Assinatura __________________________________________________________________data ____ / ____/______

NOTA ACLARATORIA
As propostas de deslocação do doente para o exterior, por estarem esgotados os recursos locais, deve ser preenchida
obrigatoriamente por um medico especialista.

Computer Shop, LDA.