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I)Identificacin
Direccin: _______________________________________________________________________________
Profesin:_____________________________________________Ocupacion:______________________________
Diagnstico medico:_______________________________________________________________________Causa
de
consulta:__________________________________________________________________________________________
Otros:____________________________________________________________________________________________
Hospitalizaciones previas:________________________________________________________________________
Antecedentes
quirrgicos:________________________________Accidentes:__________________________________
Uso de medicamentos:___________________________________________________________________________
Ocupaciones(empleos,estudios):__________________________________________________________________
Roles(familiar,social):_____________________________________________________________________________
Grupos sociales en que participa:_______________________________________________________________