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SEGUIMIENTO/ FOLLOW-UP FORM
DATOS DEL PACIENTE/ PATIENT´S INFORMATION
Fecha de Seguimiento/Date of Follow-up
MM
/
DD
/
YYYY
Numero de Verticalizador/ Stander Number
Your answer
Nombre de paciente/Name
Your answer
Fecha de Nacimiento/Date of Birth
MM
/
DD
/
YYYY
Edad/Age
Your answer
Sexo/Gender
Altura (Nota pulgadas o cm)/Height (Note feet and inches or cm)
Your answer
Peso (Nota Lib or Kg) /Weight (Note Lb or Kg)
Your answer
Direccion de Paciente/Patient's Address
Your answer
Telefono de Paciente/Patients Telephone
Your answer
Correo de Paciente/Email
Your answer
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