Fecha___________

NOMBRES:______________________APELLIDOS______________________EDAD_____

FECHADENACIMIENTO:___/___/_____DIRECCIÓN:___________________________________

______________________________ PESO:_________KG TALLA:________CM

OCUPACIÓN: __________________________________________________________________

M.C:_________________________________________________________________________

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E.A:__________________________________________________________________________

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ANTECEDENTESPERSONALES:__________________________________________________

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HÁBITOS:_____________________________________________________________________

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ANTECEDENTES FAMILIARES:___________________________________________________

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EXAMEN FUNCIONAL:__________________________________________________________

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EXAMEN FISICO SV: PA (SENTADO)______ , PA (ACOSTADO)_______

FC:_________ FR:_________

PIEL:_________________________________________________

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CABEZA:______________________________________________________________________

CUELLO: _____________________________________________________________________

ORL:__________________________________________________________________________

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CARDIOPULMONAR

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ABDOMEN::____________________________________________________________________

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PELVIS / GENITALES: ___________________________________________________________

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EXTREMIDADES::_______________________________________________________________

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NEUROLOGICO:________________________________________________________________

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PARACLINICOS

E.K.G:________________________________________________

LABORATORIO:________________________________________________________________

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ESTUDIOS DE IMÁGENES RESUMEN:

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OTRAS:_______________________________________________________________________

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DX.___________________________________________________________________________

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PLAN:_________________________________________________________________________

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