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Domiciliul legal______________________________________________________________________
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Domiciliul actual_____________________________________________________________________
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Ocupaie actual_____________________________________________________________________
Cunotine i deprinderi_______________________________________________________________
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Diagnostic clinic_____________________________________________________________________
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Diagnostic funcional_________________________________________________________________
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Tratament permanent________________________________________________________________
Nevoi speciale:
nsoitor ______________________________________________________________________
Asisten domiciliu____, servicii la domiciliu____, crucior____, triciclu____, motorciclu ____, proteze____,
orteze____, carje____, bastoane_____,alte dispozitive ajutatoare_______________
Motivul solicitrii:
Nevoi personale______________________________________________________________________
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Implicare___________________________________________________________________________
Hobby______________________________________________________________________________
Semntura beneficiar
Concluzii___________________________________________________________________________
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Asistent social