REPUBLICA BOLIVARAIANA DE VENEZUELA

MINISTERIO DEL PODER POPULAR PARA LA SALUD

AMBULATORIO URBANO III AMPARO

INFORME MEDICO
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NOMBRE DEL PACIENTE:

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EDAD: _______ SEXO F: _____ M: _____ CEDULA DE IDENTIDAD:
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IMPRESIÓN DIAGNOSTICA:
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HEA:
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EXAMEN FISICO POSITIVO:

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EXAMENES COMPLEMENTARIOS:
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DIAGNOSTICO:
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FIRMA DEL MEDICO