SCHEDA MEDICA

Dati generali:
Cognome: ______________________________ Nome: ______________________________
Nato a: ______________________________________ Il _____________________________
Residente a: ________________________________ Provincia_________________________
Indirizzo: __________________________________________________ N________
Codice Fiscale: ________________________________________________________
Gruppo sanguigno: ___________ RH: ________________
Recapiti da chiamare in caso di emergenza:
____________________________________________________________________________________
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Nome e numero di telefono del medico di famiglia:
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Vaccinazioni effettuate:
Antipolio
data ___________
Antidifterica
data ___________
Antivaiolosa
data ___________
Antipertossica data ___________
Antiepatite B data ___________
Antitetanica
data ___________
Altre:
____________________
____________________
Malattie infettive avute in passato:
1) _______________________________
2) _______________________________
3) _______________________________
4) _______________________________
5) _______________________________

data ______________
data ______________
6) _______________________________
7) _______________________________
8) _______________________________
9) _______________________________
10) _______________________________

Intolleranze alimentari:
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Allergie (indicare eventuali medicine da somministrare):
____________________________________________________________________________________
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Difetti congeniti:
____________________________________________________________________________________
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Terapie farmacologiche in corso (indicare medicinale e posologia):
____________________________________________________________________________________
____________________________________________________________________________________
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N.B.:
- allegare la fotocopia del tesserino sanitario (meglio se fotocopiato sul retro di questa scheda)
- se esistono particolari medicine da somministrare nel caso di allergie o difetti congeniti o altre terapie
in corso, specificare se i farmaci sono in possesso del partecipante e indicando anche la posologia