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NOMBRE: ____________________________________________ FECHA__________________

SEXO:_______ EDAD: ________ COMUNIDAD : ______________________________________

SIGNOS VITALES: FC:____ FR:_____ PA: ______ PESO: _____ TALLA: _____ SPO2: _____
DISCAPACIDAD: ________________________________________________________________
ANTECEDENTES RELEVANTES (cirugías, alergias, diagnósticos, etc.): ____________________
______________________________________________________________________________
______________________________________________________________________________.
_____ ________________________________________________________________________.
EXAMEN FISICO (hallazgos positivos): ______________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
INDICACIONES: ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

PACIENTE: FIRMA : ____________________________ CI: _______________________.

NOMBRE: ____________________________________________ FECHA__________________


SEXO:_______ EDAD: ________ COMUNIDAD : ______________________________________

SIGNOS VITALES: FC:____ FR:_____ PA: ______ PESO: _____ TALLA: _____ SPO2: _____
DISCAPACIDAD: ________________________________________________________________
ANTECEDENTES RELEVANTES (cirugías, alergias, diagnósticos, etc.): ____________________
______________________________________________________________________________
______________________________________________________________________________.
_____ ________________________________________________________________________.
EXAMEN FISICO (hallazgos positivos): ______________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
INDICACIONES: ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

PACIENTE: FIRMA : ____________________________ CI: _______________________.

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