A ZIENDA S ANITARIA L OCALE P ESCARA

Unità Operativa Complessa di Medicina Legale

Commissione Medica Locale Patenti di Guida
Via Pesaro n° 50 - 65121 Pescara
www.ausl.pe.it Tel. 085 425 4055 / 4058 - Fax 085 425 4045 Modello 4

DICHIARAZIONE DA FIRMARE IN PRESENZA DEL MEDICO ESAMINATORE

Il sottoscritto ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

nato/a a __________________________________________________________________________________________________________________________________________________________________________ prov. ___________________ il ______ / ______ / _____________

residente in ________________________________________________________________________________________________ via ________________________________________________________________________________________________________________________ n° ______

nell’ambito dell’accertamento medico legale per l’idoneità al conseguimento/conferma della patente di guida
di veicoli, DICHIARA, sotto la propria responsabilità e consapevole delle responsabilità derivanti da
dichiarazioni mendaci e/o reticenti, quanto segue:
SUSSISTONO:
PATOLOGIE DELL’APPARATO CARDIOCIRCOLATORIO: □ SI □ NO
□ Ipertensione arteriosa □ I.M. □ Rivascolarizzazione Miocardica □ Patologie vascolari
□ Disturbi del ritmo □ Scompenso cardiocircolatorio
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DIABETE: □ SI □ NO
□ Insulino dipendente □ Non insulino dipendente
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PATOLOGIE DELL’APPARATO RESPIRATORIO: □ SI □ NO

□ Fibrotorace □ B.P.C.O. □ Neoplasie □ ______________________________________________________________________________________________________________________________________

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PATOLOGIE NEUROLOGICHE: □ SI □ NO
□ Epilessia □ Sclerosi Multipla □ Deficit Focali □ Neoplasie □ Esiti interv. NCH □ Oligofrenia
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PATOLOGIE PSICHIATRICHE: □ SI □ NO
□ Psicosi □ Disturbi dell’affettività
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PATOLOGIE SISTEMA SCHELETRICO: □ SI □ NO

□ Esiti fratture □ Deficit articolari degli arti □ Altre patologie: _______________________________________________________________________________________________________

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MALATTIE DEL SANGUE: □ SI □ NO

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USO DI SOSTANZE PSICOATTIVE: □ SI □ NO

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MALATTIE DELL’APPARATO UROGENITALE: □ SI □ NO

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ALTRE PATOLOGIE: □ SI □ NO
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PENSIONI INVALIDITA’ CIVILE O ALTRO: □ SI □ NO

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Data: ________ / ________ / 201 ____ FIRMA _____________________________________________________________

(In caso di dichiarazione mendace si provvederà a segnalare alle competenti Autorità il caso con revisione della patente di guida, con
conseguente revoca o sospensione della stessa ai sensi degli articoli 128, 129 e 130 del Codice della Strada, così come modificati
dagli articoli 9, 10 e 11 del D.P.R. 19 aprile 1994 n.575, salvo che non si configuri ipotesi di reato).

Azienda USL di Pescara http://www.ausl.pe.it Commissione Medica Locale per le Patenti di guida Modello 04 dichiarazione anamnestica dell'utente
 COMMISSIONE MEDICA LOCALE PATENTI GUIDA ASL DI PESCARA

OSSERVAZIONI CLINICHE

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IL MEDICO ESAMINATORE

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Azienda USL di Pescara http://www.ausl.pe.it Commissione Medica Locale per le Patenti di guida Modello 04 dichiarazione anamnestica dell'utente