Datos personales

Apellidos ___________________________________________
Nombres_____________________________________________
Edad________________________________________________
Sexo________________________________________________
Fecha de nacimiento____________________________________
Direccin_____________________________________________
Si

No

Papa

Edad_______

Mama

Edad ________

Hermanos

cuantos________

Con quien vives

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Que haces en tus tiempos libres
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Si

No

Trabajas
Quien lleva el sostn de tu hogar
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Quien te ayuda en los estudios
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Cuanto es tu gasto semanal (aproximadamente)
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Datos clnicos
Peso __________________________________
Talla __________________________________
Estatura ________________________________
Contextura _______________________________
Tensin____________________________________
Alguna enfermedad que padezcas
____________________________________________________

tu

mama

papa

miembros

observacin

hipertensin
diabetes
asma
alergia
malformacin
sndrome
incapacidad
otros

Tomas algn tipo de medicamento

Datos alimenticios
consumo
frutas
jugos
vegetales
gramos
protenas
cereales
Ccomida
rapida
cafe
nicotina
alcohol
otros

Si

no

frecuencia

cantidad

tipos

Desayuno

Almuerzo|

cena

Observacin Alimenticia
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Observaciones Clnica
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