EMERGENCY CARD. about infectious diseases, food, acute professional poisoning, unusual reaction for vaccinations

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NCAD code

OKPO code of establishment _________________

The Ministry of Health and Social Development Medial documentation

of the Russian Federation

________Genesis_________________ Registration form № 058 / r

Name of medical establishment Approved by order of the Health Ministry of Russia

from 04.10.80 №1030

EMERGENCY CARD

about infectious diseases, food, acute professional poisoning, unusual reaction for vaccinations

1. Diagnosis Chronic Gastritis .

approved by the laboratory: yes, no (underline)

2. Surname, name, father´s name Ivanovic Mariah Alexandra

3. Sex F .

4. Age(for children up to 14 years-date of birth) __45 years____

__________________________________________________________________

5. Address, settlement_________Simferopol_____________ district

street ________Recchigi _____ house N ____5a___ flat N__23____

__________________________________________________________________

(individual, common, communal, write down)

6. Name and place of work(study, children´s establishment)

____________________Market ______________________________________

__________________________________________________________________

7. Dates of:

Disease ________02/03/2015___________________________________

consultation(revealed) _____________________________

establishment of diagnosis Chronic Gastritis, acute stage

last attendance to children´s establishment, school

__________________________________________________________________

hospitalization _____________________Yes_____________________

reversible side of form N 058/u

8. Place of hospitalization _____________Genesis__________________

9. If poisoning, indicate, where it took place, by which the victim was poisoned______________________________________________

__________________________________________________________________

10. Conduction of primary antiepidemiological measures and filling the document____________________________________________________

________________________________________________________________

11. Date and hour of first signalization(on telephone and other)in Russian consumer supervision

___________________02/03/2015________13:00pm_______________________

Surname of the doctor-informer __Irubor _

Who received the information_______________

12. Date and hour of sending notification__02/03/2015 13:00pm _

Signature of the doctor- informer________Irubor__

Registration N _____________ in register f. N _____________________

of Russian consumer supervision.

Signature of recipient of the notification_________

Appointed by medical personnel, in any circumstance of infectious disease, food, poisoning, acute professional poisoning or its suspicion and also in case of change in the diagnosis, it is sent to Russian consumer supervision from where such a patient is found before 12 hours from the moment of its detection.

In case of informing about change in a diagnosis in point 1 of the card, indicate the changed diagnosis, date of establishment of the diagnosis and the first diagnosis.

This card is also used in case of bites , scratch, licking by domestic or wild animals, followed by examine as it is suspicious for having rabies.

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