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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