SCHEDA INFORMATIVA SANITARIA
Cognome e Nome:
<<Cognome e nome del paziente>>	
Luogo di Nascita: 
<<Luogo di nascita>>	Data di Nascita: 
<<Data di nascita>>	

Sintesi clinico-anamnestica con particolare riferimento alle patologie invalidanti:
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Terapia in atto:
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CONDIZIONI ATTUALI

 Deficit Sensoriali:
 Grave deficit visivo (anche con Correzione).
 Grave deficit uditivo (anche con Correzione).
 Nota:
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 Deambulazione:
 Normale.
 Cammina con aiuto o assistenza.
 Presenta rischio di caduta.
 Costretto a letto, poltrona o carrozzella.
 Nota:
____________________________________________________________________________________________________________________________________________________________________________

Incontinenza:	

Si	
No	

 Urinaria:	

Saltuaria	
Permanente	

 Fecale:	

Saltuaria	
Permanente	

 Catetere vescicale.   Colostomia	

	

 Nota:
____________________________________________________________________________________________________________________________________________________________________________

 Alimentazione:
 Autonoma.
 Deve essere imboccato.
 Presenta disfagia.
 Presenta di PEG.
Presenza di magrezza patologica:	

Si	
No	

 Nota:
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 Disturbi Motori:
 Paralisi / Paresi di _______________________________________________________________________

 Instabilità motoria:	

Si	
No	

 Deficit equilibrio:	

Si	
No	

 Tendenza alle cadute:	

Si	
No	

 Nota:
____________________________________________________________________________________________________________________________________________________________________________

 Valutazione Psico-Relazionale:
 Disturbi importanti della memoria:	

Si	
No	

 Orientamento temporo/spaziale:	

Normale	
Patologica	

 Episodi di disorientamento t/s:	

Si	
No	

 Disorientamento costante:	

Si	
No	

 Disturbi della parola:	

Si	
No	

 Disturbi della comunicazione:	

Si	
No	

Nota:
____________________________________________________________________________________________________________________________________________________________________________

 Disturbi Del Comportamento:
 Agitazione Psicomotoria:	

Si	
No	

 Aggressività:	

Si	
No	

 Deambulazione Afinalistica:	

Si	
No	

 Insonnia.
Inversione del ritmo Sonno Veglia.

Utilizzo di psicofarmaci (specificare):
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 Tono Dell’Umore:           Normale           Depresso           Euforico

Pratica/ Ha praticato terapie antidepressive:	

Si	
No	

Nota:
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Presenza di Lesioni Cutanee:	

Si	
No	

Sedi e attuali medicazioni:
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Allergie:
 ____________________________________________________________________________________________________________________________________________________________________________
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Osservazioni: 
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Data di Compilazione

<<Data del certificato>>	
Timbro e firma leggibile del MMG/Medico Curante

<<Cognome e nome del medico>>