ࡱ> @bjbj 4Jg1gg1gmD> 118d,L)))7L9L9L9L9L9L9L$NtQ]L9)#)"E)^))]L118 Le,e,e,)188(7Le,)7Le,e,I0i+K`ӳ1*J$#LL0LK$>R*f>RH+K>R+K))e,)))))]L]L1,4)))L))))>R))))))))) Y : Relatrio Mdico* Medical Report* * Este relatrio mdico dever ser correctamente preenchido por um mdico especialista em doenas do foro respiratrio ou em imunoalergologia e enviado em anexo solicitao de autorizao de utilizao teraputica, visando o tratamento da asma ou da broncoconstrio induzida pelo exerccio. / * This medical report must be correctly filled by a physician specialized in respiratory diseases or in allergy and clinical immunology and sent as an annex to the request for a therapeutic use exception (Annex II) for the treatment of asthma or of exercise-induced bronchoconstriction. Nome do Praticante Desportivo / Athlete name: _____________________________________________________________________________________ Historial Mdico Completo / Comprehensive Medical History (Dever incluir: a) Antecedentes familiares de alergias, rinite ou eczemas alrgicos; b) Antecedentes pessoais de problemas respiratrios na infncia, de rinite, conjuntivite e dermatite alrgicas; c) Histria de sintomas e sinais compatveis com o diagnstico e de factores desencadeantes da crise; d) Detalhes de todas as consultas com mdicos qualificados no tratamento da asma e detalhes de idas a servios hospitalares para tratamento por exacerbao aguda de asma; e) Detalhes da medicao anti-asmtica prescrita actualmente e de toda a medicao prescrita nos ltimos 6 meses, bem como detalhes da medicao prescrita nos 3 meses anteriores aos testes de provocao; f) Resultados de testes cutneos ou de anlises que documentem a presena de hipersensibilidade alrgica). / (It should include: a) Family history of allergies, rhinitis or allergic eczema; b) Personal history of childhood respiratory problems, rhinitis, conjunctivitis or allergic dermatitis; c) History of persistent symptoms and compatible signs with the diagnostic and examples of potential provocation factors); d) Details of all consultations with physicians qualified in the treatment of asthma and details of any attendance in hospital emergency departments for treatment or admission to hospital for treatment of acute exacerbation of asthma; e) Details of the individuals currently prescribed medication and any other medication prescribed in the last 6 months, and details of medication in the 3 months prior to provocation tests; f) Results of skin prick tests or blood analysis to document the presence of allergic hypersensitivity). _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 2. Exame Clnico/ Clinical Examination (Descrio do exame clnico com especial nfase no sistema respiratrio.) / (A comprehensive report of the clinical examination with specific focus on the respiratory system.) _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 3. Anexar relatrio de espirometria: com valores absolutos e % prevista de FEV1, FVC, FEV1/FVC, bem como os traados fluxo-volume; com o resultado da espirometria aps inalao de um 2-agonsta de curta aco (se relevante); com o resultado do teste de provocao brnquica (se relevante); ou de outros testes espiromtricos necessrios confirmao do diagnstico / Add annex of report of spirometry: with FEV1, FVC, FEV1 / FVC, presented both as an actual and % predicted value, as well as flow volume tracings; the spirometry results after inhalation of a short acting Beta-2 Agonist (if relevant); a bronchial provocation test result (if relevant); or other espirometric tests needed to the confirmation of the diagnostic. Nome do Mdico/ Physician Name: ____________________________________________________ Especialidade / Medical Specialty: _____________________________________________________ Assinatura do Mdico/ Physician's Signature:___________________________________________ Data / Date: _________________________ Contactos do Mdico/ Physician's Signature: (Contactos necessrios apenas se o mdico responsvel pelo Relatrio for diferente do mdico responsvel pela solicitao de autorizao teraputica - Anexo II / Needed only if the physician responsible for the Medical Report is not the same that is responsible for the request for the therapeutic use exception - Annex II) Morada / Address: ....................................................................................... ............................................................................................................... Localidade / City: ... Cdigo Postal / Postcode: ... Pas / Country:... 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