DIABET ZAHARAT CONTROL PERIODIC

Numele ______________________ Prenumele ___________________ CNP ________________

Stare generala ____________________________________________________________________
Glicemie ___________ Hbgc __________ Glicozurie ___________ TA ___________ Puls ____
Sistem nervos central Orientat TS |_|, dezorientat |_|, Vertij |_|, Ataxie |_|, Alte tulb _____________
Reflexe osteotendinoase: ROT preznte bilateral |_|, unilateral |_| stg |_| dr|_| ___________________
Functii intelectuale normale |_|, abolite|_| altele _________________________________________
Functii affective normale |_|, afectate, altele_____________________________________________
Memorie buna |_|, alterata |_|
Acuitate vizuala buna ambii ochi |_|, alterata |_| OD |_| _____________ OS |_| ________________
Puls periferic Radiala : palpabil |_|, nepalpabil |_|, unilateral |_|, dr |_|, stg|_|, bilateral |_|
Dorsal pedis -palpabil |_|, nepalpabil |_|, unilateral |_|, dr |_|, stg|_|, bilateral |_|
Sistem venos: Fara modificari vizibile |_|, venectazii |_|, _________________ Varice |_| Mbr inf
stg |_|, dr |_|, ulcer varicos |_| localizare ______________________________________________
Atele ___________________________________________________________________________
Data ____________________
DIABET ZAHARAT CONTROL PERIODIC
Numele ______________________ Prenumele ___________________ CNP ________________
Stare generala ____________________________________________________________________
Glicemie ___________ Hbgc __________ Glicozurie ___________ TA ___________ Puls ____
Sistem nervos central Orientat TS |_|, dezorientat |_|, Vertij |_|, Ataxie |_|, Alte tulb _____________
Reflexe osteotendinoase: ROT preznte bilateral |_|, unilateral |_| stg |_| dr|_| ___________________
Functii intelectuale normale |_|, abolite|_| altele _________________________________________
Functii affective normale |_|, afectate, altele_____________________________________________
Memorie buna |_|, alterata |_|
Acuitate vizuala buna ambii ochi |_|, alterata |_| OD |_| _____________ OS |_| ________________
Puls periferic Radiala : palpabil |_|, nepalpabil |_|, unilateral |_|, dr |_|, stg|_|, bilateral |_|
Dorsal pedis -palpabil |_|, nepalpabil |_|, unilateral |_|, dr |_|, stg|_|, bilateral |_|
Sistem venos: Fara modificari vizibile |_|, venectazii |_|, _________________ Varice |_| Mbr inf
stg |_|, dr |_|, ulcer varicos |_| localizare ______________________________________________
Atele ___________________________________________________________________________
Data ____________________