Av. Florencio Jiménez, km 5, CC. Nervados Río.

Piso 01, Local

14. Barquisimeto- Edo. Lara. Teléfono: 0414- 5646864.
RIF: J-40103860-3
Dra. Nayleth Sánchez, Pediatra Puericultor; MPPS: 106.676/CML: 8170

Fecha:

HISTORIA CLINICA
Nombres y apellidos: _______________________________________________________

Edad: ______ FN: _________ Dirección: ________________________________________

Tlf.:______________ Representante: ___________________________________________

Antecedente
Prenatal:______________________________________________________________________________
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Antecedente
Perinatal:_____________________________________________________________________________
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Alimentación:__________________________________________________________________________
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Inmunizaciones:________________________________________________________________________
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Desarrollo
Psicomotor:___________________________________________________________________________
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Antecedentes Patológicos
Personales:____________________________________________________________________________
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Antecedentes Patológicos
Familiares:____________________________________________________________________________
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Examen Físico: Peso: ________ Talla: _________ CC:________ PA: __________