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Boré Djibril

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Etude des péritonites aiguës à l’hôpital Sominé Dolo de Mopti<br />

FICHE D’ENQUETE<br />

Q1-N° de la fiche :<br />

…………………………………………………..\…..\…..\…..\…..\<br />

Q2-Service :<br />

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Q3-N° du dossier :<br />

………………………………………………..……………..\…..\…..\<br />

Q4-Nom et Prénom :<br />

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Q5-Date de consultation :<br />

…………………………………\……\…..\…..\…..\…..\…..\<br />

Q6-Age :<br />

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Q7-Sexe :<br />

………………………………………………………………………..…..\…<br />

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1.masculin 2.Feminin<br />

Q8-<br />

Provenance :………………………………………………………………<br />

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BORE <strong>Djibril</strong> Thèse de Doctorat d’état en Médecine Année 2005 - 2006 77

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