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PROFESIONAL:

FICHA CLINICA
PACIENTE: ___________________________________________________
EDAD: ________________________________________________________
RUT: _________________________________________________________
FECHA NCTO: ________________________________________________
PREVISION: __________________________________________________
DIRECCION: __________________________________________________
TELEFONO: __________________________________________________
MOTIVO CONSULTA __________________________________________
DIAGNOSTICO:__________________________________________________________________________
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EVALUACION:___________________________________________________________________________
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EXAMEN
FISICO:__________________________________________________________________________________
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PLAN:___________________________________________________________________________________
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