Държавен вестник, бр. 84, 2019 г., стр. 40

СТР.  40	
Д Ъ Р Ж А В Е Н  В Е С Т Н И К 	
БРОЙ  84
 
Настоящ адрес:  ....................................................................................................................................................................................  
(област, община, град, ул., №)
  Лицето е в трудовоправни отношения                                                                                                    
Месторабота (за лица на и над 16-годишна възраст):  ......................................................................................................................  
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Диагноза на водещото заболяване 
 
 
 
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Диагнози на придружаващите заболявания  
 
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Анамнеза 
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