Диференціальний діагноз:
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Діагноз заключний клінічний:
а) основний: ____________________________________________
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б) ускладнення основного: ________________________________
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в) супутній: _____________________________________________
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Лікування: _________________________________________________
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Щоденник: _________________________________________________
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Прогноз:
Для життя:_____________________________________________
Для видужання:________________________________________
Для функції: ___________________________________________
Для трудової діяльності: ________________________________