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HISTORIA CLINICA:
MEDICINA GENERAL.
SAN CARLOS-COJEDES.
Fecha: / /
Hora:
Dr. (a):______________________________ Nº DE Historia:

o AFILIADO

o BENEFICIARIO
NOMBRES Y
APELLIDOS:________________________________________________________________________________

EDAD; _________SEXO; ________ C.I.________________ Edo. CIVIL___________________________

FNC Y LUGAR: __________________________________________________________________
DIRECCION: ______________________________________________________________________________
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PROFESION:_____________________________OCUPACION:
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_____________ AÑOS DE SERVICIOS: CODIGO:
MOTIVO DE
CONSULTA:______________________________________________________________________________________
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ANTECEDENTES
PERSONALES:____________________________________________________________________________________
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ANTECEDENTES
FAMILIARES:_____________________________________________________________________________________
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HABITOS
PSICOBIOLOGICOS:____________________________________________________________________________
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EXAMEN FUNCIONAL:
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SIGNOS VITALES: T/A._______PULSO:_______F.C.______PESO______TEMPERATURA.
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DIAGNOSTICOS:__________________________________________________________________________________
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INDICACIONES;__________________________________________________________________________________
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FIRMA: SELLO:

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