Remisiones
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The document is a referral form from the Municipal Secretary of Education's Program of Special Education and Comprehensive Care Unit in Pereira, Colombia. It contains identification information for a student being referred such as name, date of birth, age, sex, school, grade, and parents' names and contact information. The form also includes the reason for referral, observations, and health insurance information. The specialist the student is being referred to and a detailed description of the reason for referral are requested to be filled out.
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Name (Initials only): ________________________________
Age: ________________________________
Gender: M or F ________________________________
Birthplace: ___ (City/Country) ________________________________
Marital Status: ________________________________
Occupation: ________________________________
Race/ ethnic origin: ________________________________
Employer________________________________
Accompanied by, or, significant other: ________________________________
Source and reliability of information: ________________________________
Source of referral________________________________
Reason for seeking care: ________________________________
Present health or HPI (if applicable):
Present Illness (if applicable): ________________________________
Time of onset: ________________________________
Type of onset: ________________________________
Severity: ________________________________
Radiation: ________________________________
Time Relationship: ________________________________
Duration: ________________________________
Course: ________________________________
Association: ________________________________
Source of relief: ________________________________
Source of aggravation: ________________________________
II. Past Medical History (PMH):
General State of Health: ____________________________
Childhood Illnesses: _______________________________
Childhood Vaccinations: ___________________________
Adult Illnesses: ___________________________________
Past Surgeries: _________________________________
Past Hospitalizations: ______________________________
Psychiatric Disorders Diagnosed: _____________________
III. Current Health Status:
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Drugs: ________________________________
Alcohol: ________________________________
Tobacco: ________________________________
Diet: (24-hour totals) _________________________________
Screening tests: _________________________________
Sleep patterns: ________________________________
Exercise & Leisure activities: ___________________________
Environmental hazards: ________________________________
Safety measures: _ ____________________________________
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Heart disease: ________________________________
Allergies: ________________________________
Hypertension: ________________________________
Asthma: ___________________
Stroke: _____________________
Obesity: ___________
Diabetes: ________________________________
Alcoholism: ________________
Blood disorders: _______________
Mental illness: ________________
Breast cancer: _________________
Kidney disease: _______________
Cancer (other): __________________
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This document appears to be an intelligence test consisting of 5 sets of figures (A, B, C, D, E) with 40 questions total. The participant is asked to provide identifying information and the test is timed. Their raw score and percentile are calculated after completion.Enrollment-Form.docx
Enrollment-Form.docxArisHulipas2
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The document is an enrollment form for Ismael Mathay Sr. High School. It collects information such as the student's name, address, age, gender, civil status, occupation, religion, ethnicity, role in the family, guardian, disability status, highest educational attainment, reason for not attending school, availability and signatures. The form aims to gather essential student data for enrollment in the learning center.historia clinica
historia clinicayulissa poma
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This document contains a multimodal clinical history form for adults. It collects information about the patient's name, age, profession, address, phone number, date, chief complaint, triggering factors for the current episode, family history, social and family support systems, and observations. It also includes sections to summarize the patient's cognitive, affective, somatic, and interpersonal areas, and provides space for a diagnosis.Ccym application form
Ccym application formAngela Francisco
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This document is an application form for the Catholic Charismatic Youth Ministry at the University of San Jose-Recoletos for the 2015-2016 school year. It requests personal information like name, birthdate, address, family details, as well as scholastic history, hobbies, reasons for joining the ministry, and previous organizations involved in. The applicant signs and dates the bottom of the form.Remisiones
- 1. ALCALDA DE PEREIRA SECRETARA DE EDUCACIN MUNICIPAL PROGRAMA DE EDUCACIN ESPECIAL UNIDAD DE ATENCIN INTEGRAL REMISIN ESPECIALISTA FECHA: I D E N T I F I C A C I N Nombres y Apellidos _________________________________________________________________________ Lugar y Fecha de Nacimiento: ____________________________ D ____/ M_____/ A _____ Edad: ____________________ Sexo: F M Instituci坦n _________________________________________________________________________________ Grado Escolar: ______________________________ Repitente: SI NO Nombre de losPadres __________________________________________________ __________________________________________________ Direcci坦n/Tel辿fono:____________________________________________________ REMITIDO A: ________________________________________________________________________________ MOTIVODE REMISIN: (Lom叩s completoposible) _________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ OBSERVACIONES:____________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ AFILIACIN A SALUD:_________________________________________________________________________ ________________________________ Firmadel Profesional