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Disponible sur, 2018. ,
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, Annexes -Annexe 1 : Fiche d'inclusion
Inclus Fiche renseignements VigilanS Non Inclus Motif de non inclusion : Identité du sujet Nom d'usage : ????????????.. Nom de jeune fille ,
, Sexe : M F Vit seul : Oui Non Adresse complète : ?????????????????????????????????. CODE POSTAL :???????.. COMMUNE : ???????????????????? TELEPHONE 1 : ??????????../ TELEPHONE 2 : ???????????????
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, Accord des parents Noms et Prénoms titulaires de l'autorité parentale : ????????????????????????????????????????? Mairie de naissance : ???????????????????????????????? Médecin traitant : Nom Prénom : ????????????????? Lieu d'exercice : ??????????
Lieu d'exercice : ?????????? ,
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Association alcool : OUI NON Cause(s) TS si connues : ??????????????????????????????? Date d'entrée hôpital : ?? ,
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Date de sortie hôpital : ?? ,
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, Préciser les grandes lignes du « compromis de sortie «
Nom(s), prénom(s) des personnes du service ayant pris en charge et donné la carte ressource au patient ,