POLICLINICO MAS SOLIDARIO

HISTORIA CLINICA
N° H.C.: __________________
(DNI)
Fecha: ___________________
Datos del paciente: _____________________________________________________________________________________
Alérgico(a):____________________________________ Edad: ________________ Sexo: F_____ M______
Fecha de nac.:______/______/__________Celular:______________________Ocupacion:_____________________________
Dirección: _______________________________________________________________________________________________

Signos vitales:
P.A________________Mmhg F.C______X1 T°_______C° Psto2_______% Peso ________Kg Talla _______CM FR: ________X1

Antecedentes:
A.-Familiares: __________________________________________________________
B.-Patológicos: 1.- Diabetes mellitus: SI_____NO_____
2.- Hipertensión arterial: SI_____ NO_____
3.- Asma Bronquial SI_____ NO_____
4.- Otros (Especificar): ________________________________
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FIRMA TEC. ENFERMERA
Motivo de consulta: ___________________________________________________________________________________
Anamnesis: __________________________________________________________________________________________
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Examen físico: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Impresión diagnóstico:

 ______________________________________________________________________________________________________
 ______________________________________________________________________________________________________

Exámenes complementarios:______________________________________________________________________________________

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Tratamiento:____________________________________________________________________________________________________
_______________________________________________________________________________________________________________
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Próxima cita medica: _____________________________________________________________________________________

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Firma y sello del medico

Horario de Atención: 7 am – 7pm

Av. Tupac Amaru Casn Mza. G Lote. 7 Lima - Lima – Comas
Email: policlinico.mas.solidarios@gmail.com