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Historia clínica.

1.  Datos de Filiación

 Nombres:_________________________________________________________________ 

C.I.:______________________________________________________________________ 

Edad: ____________________________________________________________________ 

Sexo: ____________________________________________________________________ 

Raza: ____________________________________________________________________ 

Estado civil: _______________________________________________________________ 

 Número de hijos: ___________________________________________________________ 

Instrucción: _______________________________________________________________ 

u!ar " #echa de Nacimiento: _________________________________________________ 

u!ar de $rocedencia: _______________________________________________________ 

%cu&ación anterior: _________________________________________________________ 

%cu&ación actual:___________________________________________________________ 

u!ar de Residencia anterior:_________________________________________________ 

u!ar de residencia actual:____________________________________________________ 'echa de in!reso: ___________________________________________________________ 

(os&italización: ____________________________________________________________ 

'echa de (istoria Cl)nica: ____________________________________________________ 

*utor: ___________________________________________________________________ 

2.  Motivo de Consulta

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3.  Evolución de la Enfermedad

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4.  Revision de aparatos sistemas.

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!.  Emuntorios.

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".  #ntecedentes $atoló%icos $ersonales

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&.  #ntecedentes $atoló%icos Familiares

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'.  H()itos.

*lcohol: __________________________________________________________________ 

+abaco: __________________________________________________________________ 

,ro!as: __________________________________________________________________ 

Ca#-: ____________________________________________________________________ 

+e: ______________________________________________________________________ 

*.  #limentación.

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