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Ppersonal Data:

Name:
Last name:
Address:
Zip code:
Country:

City:
E-mail:
Phone:
Image:

Clinical Data:

Age: Gender:
Height: Weight:
Children:
Yes No
 How many Children:
Surgeries: Yes No
Cancer: Yes No

Diabetes:

 Yes No
Hypertension: Yes No Presión: S/D
Relatives with cancer: Yes No  
Relatives with Diabetes: Yes No

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