Examen Fsico:

Peso_____(Kg)

Talla_____(cm)

Estado Nutricional:_____________________________

Piel y Mucosa___________________________________________________________________________________
_______________________________________________________________________________________________
T.C.S:_________________________________________________________________________________________
Aparato Respiratorio:____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Aparato Cardiovascular:_________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Abdomen:______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
S.N.C:_________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Exmenes Complementarios:______________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Impresin Diagnostica:___________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Conducta a seguir:______________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Firma y Sello

Horario de Culminacin___________________________

Del mdico:
Prxima Consulta_____________________________________
TCE: Tejido celular subcutneo.
SNC: Sistema nervioso centra

Repblica Bolivariana de Venezuela

Misin Mdica Cubana

Barrio Adentro

HISTORIA CLINICA INDIVIDUAL

No. De H. Clnica________________
Nombre

Apellidos:______________________________________________________________________
Edad:___________

Sexo:__________

Fecha de

Nacimiento______/______/____________
Direccin

Particular:

_____________________________________________________________________
_______________________________________________________________________________________
Estado________________
Municipio______________________________________________
ASIC:____________________________
Consultorio:_________________________________________
A.P.P:
_________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
A.P.F:
________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Vacunacin:
____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reaccin
a
medicamentos:
_______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Otras
Alergias:
__________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Nombres y Apellidos del Paciente: _________________________________ No. H.
Clnica______________