HISTORIA CLINICA
Nombres y Apellidos: ______________________________________________________________________
Cédula: ___________ Fecha de nacimiento: ___/___/____ Edad: _____ Nº Teléfono: ____________________
Procedencia por estado: _________________ Nacionalidad: V____ E____ Ocupación: ___________________
Religión: __________________
Dirección: _________________________________________________________________________________
EN CASO DE EMERGENCIAS
Avisar a: ____________________________________ Parentesco: _______________ Teléfono: ____________
Motivo de Consulta: ________________________________________________________________________
ENFERMEDAD ACTUAL
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APP: ____________________________________________________________________________________
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Qx: ______________________________________________________________________________________
Transfusiones sanguíneas: ____________________________________________________________________
Tx: ______________________________________________________________________________________
Alergias: __________________________________________________________________________________
APF:_____________________________________________________________________________________
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