[RTF]
{\rtf1\ansi\ansicpg1252\deff0{\fonttbl{\f0\froman\fcharset1 Tahoma;}{\f1\fswiss\fcharset0 Arial;}}{\colortbl\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0;\red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue127;\red0\green127\blue127;\red0\green127\blue0;\red127\green0\blue127;\red127\green0\blue0;\red127\green127\blue0;\red127\green127\blue127;\red192\green192\blue192}{\info{\operator       Sergio Luzzi Galeazzi}{\author       Sergio Luzzi Galeazzi}{\creatim\yr1996\mo9\dy19\hr9\min2\sec17}{\revtim\yr1996\mo12\dy7\hr3\min33\sec58}{\printim\yr1996\mo12\dy15\hr11\min13\sec41}{\version1}{\vern262367}}\paperw11903\paperh16835\margl407\margr0\margt815\margb0\deftab849\pard\ql\li144\fi0\ri119{\field{\*\fldinst{\b\i\f1\fs28\cf0\up0\dn0 USER_NOME}}{\fldrslt{\b\i\f1\fs28\cf0\up0\dn0 Utente: Nome e cognome}}}{\par}\pard\ql\li144\fi0\ri119{\i\f1\fs20\cf0\up0\dn0 Medico Chirurgo}{\par}\pard\ql\li144\fi0\ri119{\field{\*\fldinst{\i\f1\fs20\cf0\up0\dn0 USER_TIT}}{\fldrslt{\i\f1\fs20\cf0\up0\dn0 Utente: Titoli professionali}}}{\par}\pard\ql\li144\fi0\ri119{\field{\*\fldinst{\i\f1\fs20\cf0\up0\dn0 USER_IND}}{\fldrslt{\i\f1\fs20\cf0\up0\dn0 Utente: Indirizzo}}}{\par}\pard\ql\li144\fi0\ri119{\field{\*\fldinst{\i\f1\fs20\cf0\up0\dn0 USER_CAP}}{\fldrslt{\i\f1\fs20\cf0\up0\dn0 Utente: CAP}}}{\i\f1\fs20\cf0\up0\dn0  }{\field{\*\fldinst{\i\f1\fs20\cf0\up0\dn0 USER_CITTA}}{\fldrslt{\i\f1\fs20\cf0\up0\dn0 Utente: Citta}}}{\par}\pard\ql\li144\fi0\ri119{\i\f1\fs20\cf0\up0\dn0 Tel. }{\field{\*\fldinst{\i\f1\fs20\cf0\up0\dn0 USER_TEL}}{\fldrslt{\i\f1\fs20\cf0\up0\dn0 Utente: Telefono}}}{\i\f1\fs20\cf0\up0\dn0  Fax 0108398552}{\par}\pard\ql\li144\fi0\ri119{\i\f1\fs20\cf0\up0\dn0 www.studiomedicodestefanis.it}{\par}\pard\ql\li144\fi0\ri119{\b\f1\fs20\cf0\up0\dn0 ________________________________________________________________________________________________}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\tx5673\ri119{\f1\fs20\cf0\up0\dn0\tab}{\field{\*\fldinst{\f1\fs18\cf0\up0\dn0 USER_CITTA}}{\fldrslt{\f1\fs18\cf0\up0\dn0 Utente: Citta}}}{\f1\fs18\cf0\up0\dn0  li }{\field{\*\fldinst{\f1\fs20\cf0\up0\dn0 XVI_DATA}}{\fldrslt{\f1\fs20\cf0\up0\dn0 GG.MM.AA}}}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs24\cf0\up0\dn0 Si certifica che, sulla scorta dei dati anamnestici e clinici in mio possesso, che}{\par}\pard\ql\li144\fi0\ri119{\f1\fs24\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_SIG}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 Il Sig.}}}{\b\f1\fs20\cf0\up0\dn0  }{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_NOME}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 ASSIRELLI MARIA}}}{\par}\pard\ql\li144\fi0\ri119{\b\f1\fs20\cf0\up0\dn0 nat}{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_MF}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 ?}}}{\b\f1\fs20\cf0\up0\dn0  a }{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_LNASC}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 Luogo nascita}}}{\b\f1\fs20\cf0\up0\dn0  (}{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_PNASC}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 PN}}}{\b\f1\fs20\cf0\up0\dn0 ) il }{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_DNASC}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 D Nascit}}}{\par}\pard\ql\li144\fi0\ri119{\b\f1\fs20\cf0\up0\dn0 residente in }{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_IND}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 Paziente: Indirizzo}}}{\par}\pard\ql\li144\fi0\ri119{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_CAP}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 C A P}}}{\b\f1\fs20\cf0\up0\dn0  }{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_CIT}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 Paziente: Cittą}}}{\par}\pard\ql\li144\fi0\ri119{\field{\*\fldinst{\b\f1\fs20\cf0\up0\dn0 XPA_CODFIS}}{\fldrslt{\b\f1\fs20\cf0\up0\dn0 CFCFCFCFCFCFCFCF}}}{\par}\pard\ql\li144\fi0\ri119{\b\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs24\cf0\up0\dn0 da me in cura  da }{\b\f1\fs24\cf0\up0\dn0 PIU' }{\f1\fs24\cf0\up0\dn0  /  da }{\b\f1\fs24\cf0\up0\dn0 MENO}{\f1\fs24\cf0\up0\dn0        }{\b\f1\fs24\cf0\up0\dn0 di un anno}{\par}\pard\ql\li144\fi0\ri119{\b\f1\fs24\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\b\f1\fs24\cf0\up0\dn0 PRESENTA  /  NON PRESENTA }{\f1\fs24\cf0\up0\dn0  pregresse condizioni morbose che possono costituire}{\par}\pard\ql\li144\fi0\ri119{\f1\fs24\cf0\up0\dn0  un rischio attuale per la Guida, in rifeirmento a}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 APPARATO CARDIO-CIRCOLATORIO                                                                                              SI    NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 (Se SI, specificare diagnosi)}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 DIABETE MELLITO                                                                                                                             SI    NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 SISTEMA ENDOCRINO                                                                                                                      SI     NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 (Se SI, specificare diagnosi)}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 PATOLOGIE PSICHICHE                                                                                                                    SI     NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 (Se SI, specificare diagnosi)}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 EPILESSIA                                                                                                                                           SI     NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 CONDIZIONI DI DIPENDENZA DA:   }{\b\f1\fs20\cf0\up0\dn0 ALCOL                                                                                     }{\f1\fs20\cf0\up0\dn0 SI      NO}{\par}\pard\ql\li144\fi0\ri119{\b\f1\fs20\cf0\up0\dn0                                                     SOSTANZE STUPEFACENTI                                                         }{\f1\fs20\cf0\up0\dn0 SI      NO}{\b\f1\fs20\cf0\up0\dn0  }{\par}\pard\ql\li144\fi0\ri119{\b\f1\fs20\cf0\up0\dn0                                                     SOSTANZE   PSICOTROPE                                                           }{\f1\fs20\cf0\up0\dn0 SI       NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 APPARATO URO-GENITALE:  Insufficienza renale grave                                                                  SI      NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 SANGUE ED ORGANI EMOPOIETICI: Sindromi emofiliche, Linfomi o Leucemie in trattamento              SI      NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 APPARATO OSTEO-ARTICOLARE: gravi alterazioni anatomiche o funzionali                                         SI      NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0 ORGANI DI SENSO: gravi patologie visive evolutive                                                                                SI       NO}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\tx3326\ri119{\i\f1\fs20\cf0\up0\dn0\tab}{\field{\*\fldinst{\i\f1\fs20\cf0\up0\dn0 USER_NOME}}{\fldrslt{\i\f1\fs20\cf0\up0\dn0 Utente: Nome e cognome}}}{\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0\par}\pard\ql\li144\fi0\ri119{\f1\fs20\cf0\up0\dn0             TIMBRO                                                                                             FIRMA}{\par}\pard\ql\li144\fi0\ri119}
[Opzioni]