ficha clínica

Nombre: _______________________________ Edad: _______ Sexo: _____

Fecha de nacimiento: _____________________ Ocupación: ___________________

Residencia:______________________________ Estado civil: _______________
Servicio:________________________________

Antecedentes Heredofamiliares:

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Enfermedad actual:

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Antecedentes personales no patologicos

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Antecedentes personales patologicos:

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