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SECCIÓN:
Fecha: Hora:
FICHA DE IDENTIFICACIÓN
Nombre:
Religión:
Dirección:
Teléfono _______________________________
Ingiere alcohol:
Consume tabaco:
Hecho que le haya causado tristeza a lo largo de su vida y de tres años a la fecha:
Ha sufrido intentos o ideas de suicidio:
*C
*A
*S
*I
*C
Pruebas aplicadas:
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NARRACIÓN DE LOS HECHOS
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Etiología: ________________________________________________________________________
Comentarios:_____________________________________________________________________
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Peligrosidad: _____________________________________________________________________
GENOGRAMA Fecha de elaboración:_______________