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Est su ni o actualmente tomando medicina recetada por un doctor circule uno Si No Si es s favor de enlistar las medicinas y la raz n por qu las toma. 2. Fecha de Nacimiento Maestro/Grado Direcci n Madre/Tutor de tel fono Casa/Cell N mero del Trabajo Compa a de Seguro Tipo de Covertura B sico circule uno Si Lentes de Contacto circule uno Si Covertura M dica Mayor/principal circule uno Si P liza/ N mero de Grupo opcional 1. Tiene su ni o reacci n al rgica a alg n tipo de medicina circule uno Si...
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