CONSULTORIO MEDICO POPULAR CASITAS II

HISTORIA CLINICA

FECHA: ___________ HORA: ________

NOMBRES Y APELLIDOS:_________________________________________________________

CEDULA: V-__________ EDAD: ______ TELEFONO: _____________ FECHA Y LUGAR DE NAC:

_____________ ESTADO CIVIL: __________ PROFESION: _________________ OCUPACION U
OFICIO: ____________ DIRECCION DE HAB: _________________________________________

EN CASO DE EMERGENCIA AVISAR A: _________________________ PARENTESCO: _________

DIRECCION Y TELEFONO: _______________________________________

MOTIVO DE CONSULTA: ___________________________________________________

HISTORIA DE ENFERMEDAD ACTUAL:_______________________________________________

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APP:_________________________________________________________________________
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APF:_________________________________________________________________________
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ALERGIA A MEDICAMENTO: ___________________ VACUNACION: _____________________

OPERACIONES: ____________________ TRAUMATISMO: _________________ HABITOS
TOXICOS: _______________________ TRANSFUCIONES: _________________________

GENERO DE VIDA

VIVIENDA TIPO: ________ PAREDES:__________ PISO:________TECHO:_____

HABITACIONES: ______ HABITANTES: ____ HACINAMIENTO: ________ BAÑO TIPO:

_________ AGUAS BLANCAS: _____ AGUAS NEGRAS: _____ ANIMALES DOMESTICOS:
________________ VECTORES:_______ ROEDORES: ______ HIGIENE DE LA CASA Y LOS
ALIMENTOS: ___________ HORAS DIARIAS DE DESCANSO Y RECREACION: ________ HORAS
DE TRABAJO: _______

EXAMEN FISICO
PESO: _____ TALLA: _____ IMC: ____ T.A: __________ FC: _____ F.R: ______ TEMP:_______

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IDX: _________________________________________________________________________

LABORATORIOS: _______________________________________________________________
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ECOSONOGRAMA: _____________________________________________________________

PLAN: ________________________________________________________________________
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PENDIENTE: ___________________________________________________________________
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PROXIMA CITA: ________________________________________________________________

FIRMA Y SELLO DEL MEDICO: _________________ SELLO INSTITUCION:__________________