Ficha Nº

MUNICIPALIDAD DE LAS CONDESDIRECCION DE DESARROLLO COMUNITARIO

SENDA PREVIENE LAS CONDES

F.A.I.S(Ficha de Acogida Ingreso y Seguimiento)

Fecha de Ingreso

I. Datos Personales (Directo)

NOMBRES APELLIDO PATERNO APELLIDO MATERNO

RUT FECHA DE NACIMIENTO EDAD

GENERO ESTADO CIVL ACTIVIDAD

NIVEL EDUCACIONAL SISTEMA DE SALUD COMUNA

TELEFONO FIJO TELEFONO MOVIL SECTOR

DIRECCION

II. Datos de personas que viven con el beneficiario

NOMBRE RUT PARENTESCO ACTIVIDAD ECONÓMICA

1.2.3.4.5.6.

III. Derivación LUGAR DE DETECCIÓN DERIVADO A:

FECHA DE DERIVACIÓN ASISTE A CITACIÓNSI__ NO__

INGRESA AL PROGRAMA DE REHABILITACIÓN NOMBRE DE CENTRO DE RR.HH AMBULATORIO__ RESIDENCIAL__

TIPO DE SEGUIMIENTO: TIEMPO DE SEGUIMIENTO1. Telefónico ___2. Visita Domiciliaria ___ ESTADO DEL USUARIO

TRATAMIENTOS ANTERIORES1. Si ____2. No ____

DURACION DEL TRATAMIENTO: __________

SUSTANCIA( S) CONSUMIDA (S) :

PATOLOGÍA(S) PREEXISTENTES (S) :

IV. Datos de familiar significativo

NOMBRES APELLIDO PATERNO APELLIDO MATERNO

RUT PARENTESCO TELEFONO DE CONTACTO

DIRECCION

V. Observaciones

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