Психиатр

На освидетельствование врачом-психиатром согласен(на) _____________________

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"__" ________________ 20__ г.

(месяц прописью)

Восприятие: _______________________________________________________________

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Интеллектуально-мнестическая сфера: _______________________________________

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Диагноз: __________________________________________________________________

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Заключение: _______________________________________________________________

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"__" ________________ 20__ г. _____________ ___________________

(месяц прописью) (подпись) (расшифровка)