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CENTRO DE ESPECIALIDADES FIODAN

Su satisfacción es nuestro confort…


EL PANGUI, ECUADOR

Paciente: N° Historia Clínica:


C.I.: Edad:
F. Nacimiento: Estado Civil:
Dirección: Etnia:
Teléfono: Sexo:

Tipo de Fecha: Hora de Hora de


visita Entrada: Salida:

MOTIVO DE LA CONSULTA
______________________________________________________________________________________________________
ANTECEDENTES
ANTECEDENTES PATOLÓGICOS PERSONALES: ______________________________________________________
ANTECEDENTES PATOLÓGICOS FAMILIARES: _______________________________________________________
ANTECEDENTES QUIRÚRGICOS: ____________________________________________________________________
HOSPITALIZACIONES: _______________________________________________________________________________
ENFERMEDAD ACTUAL
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
SIGNOS VITALES Y ANTROPOMÉTRICOS:
PESO: _____ KG TALLA: _____ mts. IMC: _____/______________ TA: ____/_____mmHg
FC: ______ X´ FR: _____ X´ SatO2: ______ % T: _____ °C

EXAMEN FÍSICO
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______________________________________________________________________________________________________
______________________________________________________________________________________________________
DIAGNÓSTICO
______________________________________________________________________________________________________
TRATAMIENTO
______________________________________________________________________________________________________
MEDICACIÓN
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
INDICACIONES
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
PRÓXIMA CITA
_________________________________
FIRMADO
_________________________________
C.I.: ___________________ FIRMA
EVOLUCIÓN
HORA: FECHA:

SIGNOS VITALES Y ANTROPOMÉTRICOS:


PESO: _____ KG TALLA: _____ mts. IMC: _____/______________ TA: ____/_____mmHg
FC: ______ X´ FR: _____ X´ SatO2: ______ % T: _____ °C

NOTAS DE EVOLUCIÓN
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

TRATAMIENTO
______________________________________________________________________________________________________

MEDICACIÓN
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
INDICACIONES
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________

PRÓXIMA CITA
_________________________________
FIRMADO
_________________________________
C.I.: ___________________ FIRMA
EVOLUCIÓN
HORA: FECHA:

SIGNOS VITALES Y ANTROPOMÉTRICOS:


PESO: _____ KG TALLA: _____ mts. IMC: _____/______________ TA: ____/_____mmHg
FC: ______ X´ FR: _____ X´ SatO2: ______ % T: _____ °C

NOTAS DE EVOLUCIÓN
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

TRATAMIENTO
______________________________________________________________________________________________________

MEDICACIÓN
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
INDICACIONES
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________

PRÓXIMA CITA
_________________________________
FIRMADO
_________________________________
C.I.: ___________________ FIRMA
EVOLUCIÓN
HORA: FECHA:

SIGNOS VITALES Y ANTROPOMÉTRICOS:


PESO: _____ KG TALLA: _____ mts. IMC: _____/______________ TA: ____/_____mmHg
FC: ______ X´ FR: _____ X´ SatO2: ______ % T: _____ °C

NOTAS DE EVOLUCIÓN
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

TRATAMIENTO
______________________________________________________________________________________________________

MEDICACIÓN
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
INDICACIONES
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________

PRÓXIMA CITA
_________________________________
FIRMADO
_________________________________
C.I.: ___________________ FIRMA
EVOLUCIÓN
HORA: FECHA:

SIGNOS VITALES Y ANTROPOMÉTRICOS:


PESO: _____ KG TALLA: _____ mts. IMC: _____/______________ TA: ____/_____mmHg
FC: ______ X´ FR: _____ X´ SatO2: ______ % T: _____ °C

NOTAS DE EVOLUCIÓN
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

TRATAMIENTO
______________________________________________________________________________________________________

MEDICACIÓN
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
INDICACIONES
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________
 _______________________________________________________________________________________________

PRÓXIMA CITA
_________________________________
FIRMADO
_________________________________
C.I.: ___________________ FIRMA