HISTORIA CLINICA

Nombre y Apellidos: ________________________________________________________________________________.

Edad: ________ Fecha de Nacimiento:___/_____/_____.Cedula de Identidad: _________________________________.
Sexo: Masculino______ Femenino______.
Estado Civil: Casado/a____, Divorciado/a_____, Viudo/a_____, Concubino/a_____.
Dirección de Habitación: _____________________________________________________________________________.
Religión: _________________________. Ocupación: __________________________ Responsable: ________________,
Parentesco: __________________.
Número de Teléfono: ______________________________.
MOTIVO DE CONSULTA:
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ENFERMEDAD ACTUAL:
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ANTECEDENTES MEDICOS
Enfermedades:______________________________________________________________________________________
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Intervenciones quirúrgicas:
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Alergias:___________________________________________________________________________________________
Hábitos: Tabaco__________________________, Alcohol_____________________________,
Alimenticios________________________________________________________________________________________
Drogas_______________, Patrón de sueño_____________________________, Café__________________
EXAMEN FISICO:
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DIAGNOSTICO DIFERENCIAL:
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EXAMENES COMPLEMENTARIOS:
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