HISTORIA CLINICA

Datos de identificacin

Fecha y hora: ___/___/___ __:__

Nombre y Apellidos: _______________________________Nmero de Identificacin:

___________

Sexo: _____________ Fecha de Nacimiento: ___/___/_____ (________) Estado civil:

___________

Lugar de nacimiento: _______________ Direccin:

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Profesin u Ocupacin: _______________________ Tipo de vivienda:

_______________________

Raza: _________________ telfono: ______-_____________

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Acompaante: ____________________ Parentesco: ___________ Telfono: _____-

____________

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