HISTORIA CLINICA

NOMBRES Y APELLIDOS: __________________________________________________________

EDAD: ________
LUGAR Y FECHA DE NACIMIENTO: __________________________________________________
INSTRUCCIÓN: _____________________________
OCUPACIÓN: ______________________________
N° DE HERMANOS: __________________________
PADRE: __________________________________________________________________________
MADRE: _________________________________________________________________________
MOTIVO DE CONSULTA:
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DIÁGNOSTICO PRESUNTIVO:
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