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    2 views1 page

    Plantilla Respuesta (Imprime 8)

    Uploaded by

    josesanchezfuertes

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    ■ NÚMERO DE MESA: xxxx

    VERSIÓN DEL CUESTIONARIO: XX


    MINISTERIO NÚMERO DE EXPEDIENTE: XXXXX-XXXXXXXXXXXXXX
    xxxxxxxxxxxx
    DE SANIDAD, CONSUMO
    Y BIENESTAR SOCIAL NIF/NIE O PASAPORTE:
    APELLIDOS Y NOMBRE xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx farmaFIR

    CON rnoL

    --------�--------------------------------- -■
    1 1 1 1
    2 3 4 1 12131 4 1 1 2 1 3 1 4
    46 I 11 1 l íl • 1nr1r1 146 nD r1 n
    CONTROL
    □ □
    41 D O 91n n no 147 □□□□
    48 0 o o o •□□ no 148 □□ DO □
    490□ □ D g9□□□□ 149 □□□ 3 4

    l I Z 1 3 1 4 5QO o oo 100 □□□□ 150 □□□□ □□


    10 □□ □ SI□ □o o 101□□□□ 151 □□□□ □
    ll 1 1 1nI l 52 1 1 l 1 7 íl 102 n n 11 r 1 152 n n 11 n
    30 □□ □ □□□
    53 O 103 □□□□ 153 □□□□
    4n n □ n 54nnnn 104nnnn 154 nnnn
    so □□□ 55□□ □ □ 105 □□□□ 15S □□□□
    Efl[J □ íl □[
    56 r r 1 J 106 l n íl □ 156 □ f l f7 □
    □□ □ □ 57□□□□ 107□□□□ 157 □□□□
    n11r1 □
    1
    sn n n 11 SI 1 □
    11 n 108 158 □ [J 11 □
    90 □ □□ 590 n no 109no □□ 159 □□□□
    10n nn n 60n n n n 110 nnnn 1� nnnn
    uo □□□ 610 no o 111 □ no□ 161 □ n o□
    i.2flíl □ fl 62 r r 1 r1 n 112 l íl íl □ 162 n r 1 r1 □
    130 □□ □ 630 □□ □ 113 □□□□ 163 □□□□
    14 r 1 n □ r 1 64 r r
    r1 r1 J 114 1r1.r1n 16-4 n r1 r1 n
    15 o n n □ 650 □□□ us'□□□□ 165 □□ □ □·
    1� r 1 o o r 1 66 r r 1 r1 o 116 r1 r1□ o 166 □ 111 l □
    11□□□□ 670 □□ □ 117 □□□□ 167 □□□□
    unnnn 68 I n 11 n 118 1l Il Il Il 168 11 n n n
    190 □□□ 690 □□ □ 119 □□□□ 169 □□□□
    zon □ □ n 1qn n n n 1211nnnn 170 □ □ fl n
    210 □□□ 110 □□ o. 121 □□□□ 171 □□□□
    22 r1 o n r1 noor1 □ 122 r I r In 11 172 □□□□
    230□□ □ no □□□ 123□□□ □ 173 □□□□
    zq1n □ r1 74 1 n r 1 r1 124 r7 rl n I l 174 o 11 o n
    25□ O O O 75 □□ □ □ 125 □□□□ 175 □□□□
    ZEn O O n 16n nn n 126 11 11 nn 176 nnnn
    27□□□□ no □□□ 127□□□□ 177 □□□□
    2sno11 □ 1u íl O n 128 ílfl[Jfl 171 íl fl Tl n
    29O O O O 790 □□□ 129 □□□□ 179 □□□□ mD O
    3on O n n son □ nn 130 nnnn 180 r1 n n n
    310 □□□ s1O O O O 131
    □□□□ 181 □□□□ RESERVAS

    □
    º-8- 0
    a,O O O 82 1 0 fl 0 132 r 1 r 1 n 11 1� r Ir 111 n
    □□□
    226
    non □□ 83 r 0 íl 0 133 □□□□ 183
    □o 221 D
    □ nn □ □□□
    84 1 134□□ no 184 110 0 228 000
    □□□
    34

    35 □□ □□ sso 135□□□□ 185 □□□□


    3Ennnn 16 I n II n 136 1 1 1 l n 11 186 11111,n
    370 □ □ □ 87□□ □ □ 137□□□□ 187 □□□□
    38 n n□ n 11 nnoo 138 nnnn 18lf nnn □
    39 □ □ □□ 8900 □□ 139□□□□ 189 □ □□□
    íl O□ 0 □ □
    90 0 o 140 r7r1 □ r1 190□□□□
    □ □ □□
    40
    41 91□□□ □ 141 □□□□ 191 □□□□ □ □ □□
    235

    42 non n 92nnnn 142 nnnn 192 r1 r1 nn


    43 o o o r 1 93□□□ □ 143 □□□□ 193
    □ □□□
    44r-1n □□ 94 0 íl n 144□□□□ 194 111111 n
    450 o □□ 950□□ □ 145□□□□ 195 □□□□
    ■ EJEMPLAR PARA LA ADMINISTRACIÓN ■

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