Ô.È.Î._______________________________________________________________________
Âîçðàñò______________îáðàçîâàíèå _________________________äàòà_______________
Æàëîáû _____________________________________________________________________
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Ñóáòåñò 1. ÎÑÂÅÄÎÌËÅÍÍÎÑÒÜ
Ñóáòåñò 10.
Ñóáòåñò 11.