ࡱ> $7bjbjnvgvg.'N N D%%%d |%Tovvvnnnnnnn$svtnvvvvvnovjnvn[fn c76iLn$o0Togi8vZvnvn vvvvvvvnnpvvvTovvvvvvvvvvvvvvN Y : Spett.le INARCASSA DIREZIONE ATTIVIT ISTITUZIONALI Ufficio Ciclo Passivo Via Salaria, 229 - 00199 Roma protocollo@pec.inarcassa.org REVISIONE PENSIONE DI INVALIDIT / INABILIT V E R B A L E V I S I T A M E D I C A - C A R T E L L A C L I N I C A relativa a: Cognome e Nome: _______________________________________________________________________________ Comune di Nascita: _________________________ (_____) Data di nascita: ___/___/_____ Et (anni):_________ residente a: (Citt) ___________________________________ (Prov.) ____________________________________ (Via)____________________________________________________________n. ________ (Cap) ______________ identificato a mezzo di: _______________________________________ n.__________ rilasciato il _____________ STATO CIVILE: ( Celibe/Nubile ( Coniugato/a ( Vedovo/a ( Con prole ( Senza prole Descrizione dellattivit lavorativa: PRIMA DELLEVENTO: __________________________________________________________________________ ______________________________________________________________________________________________ _____________________________________________________________________________________________ DOPO LEVENTO: ______________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ A. ANAMNESI Anamnesi / Precedenti familiari: __________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Patologica remota: ____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Patologica prossima: ___________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ DOCUMENTAZIONE MEDICA (da allegare obbligatoriamente) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________ Esami complementari: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________ B. INDAGINI GENERALI Costituzione generale: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Stato di nutrizione: __________________________________________________________________________________________ ___________________________________________________________________________________________ Stato di sanguificazione: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Muscolatura: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Apparato Linfatico: _______________________________________________________________________________________________ _______________________________________________________________________________________________ ______________________________________________________________________________________________ C. INDAGINI SPECIALI Cute e tessuto sottocutaneo: _____________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ _____________________________________________________________________________________________ ______________________________________________________________________________________________ Apparato osteoarticolare: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _______________________________________________________________________________________________ Sistema nervoso: ______________________________________________________________________________________________ _ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Psiche: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Organi di senso: ______________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Apparato cardio-vascolare: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Apparato fonetico respiratorio: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Addome: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Apparato genito-urinario: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ D. EPICRISI MEDICO LEGALE In data __ / __ / ____ , stato sottoposto a visita medica di REVISIONE: Nome e Cognome: Ing./Arch. ______________________________________________________________________ Nato/a a: _______________________________________________________________ (_____) il: ___/___/_____ PENSIONE IN GODIMENTO: Invalidit dal ___/___/_____ Inabilit dal ___/___/_____ DIAGNOSI MEDICO LEGALE ATTUALE _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ A causa della malattia / infortunio di cui alla diagnosi, la capacit delliscritto allesercizio della professione ancora esclusa in modo permanente e totale (INABILIT). A causa della malattia / infortunio di cui alla diagnosi, la capacit delliscritto allesercizio della professione non pi esclusa in modo permanente e totale (NON INABILE). _____________________________________________________________________________________________ A causa dellinfermit o difetto fisico o mentale, di cui alla diagnosi, la capacit delliscritto allesercizio della professione oggi ridotta in modo continuativo a meno di un terzo (INVALIDO). A causa dellinfermit o difetto fisico o mentale, di cui alla diagnosi, la capacit delliscritto allesercizio della professione non pi ridotta in modo continuativo a meno di un terzo (NON INVALIDIT PENSIONABILE). Luogo _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Data ____/____/_____. In fede Timbro e firma del medico _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SEZIONE RISERVATA AL CONSULENTE CENTRALE CONVALIDAZIONE DEL GIUDIZIO ( IL GIUDIZIO CONVALIDATO ( IL GIUDIZIO NON CONVALIDATO LInabilit in godimento confermata: INABILE Il professionista, gi inabile, oggi invalido in quanto la capacit allesercizio della professione oggi ridotta in modo continuativo a meno di un terzo: INVALIDO Linvalidit pensionabile in godimento confermata: INVALIDO Per la natura e levoluzione dellinfermit in diagnosi indicata ulteriore revisione al ____/____/_____ Data ____/____/_____. 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