NOMBRE: ________________________________________________________ EDAD: __________________

DOMICILIO: ______________________________________________________ TIPO DE SANGRE: _________

RELIGIÓN: _____________ ESTADO CIVIL: CASAD@ SOLTER@ VIUD@

OCUPACIÓN________________________ LUGAR DE NACIMIENTO: _________________________________

GENERO: M F

LUGAR DE RESIDENCIA: _______________________ NUMERO DE TELEFONO: _________________________

ESCOLARIDAD: KINDER PRIMARIA SECUNDARIA PREPARATORIA UNIVERSIDAD

OTROS

ANTECEDENTES FAMILIARES:

DIABETES HIPERTENSION ENFERMEDADES ENFERMEDADES

CARDIACAS VENERIAS
ASMA HEMOFILIA CANCER ANEMIA

EPOC EVENTO CEREBRO SINDROME ENFERMEDAD RENAL

VASCULAR METABOLICO CRONICA
MADRE PADRE ABUELOS HERMANOS

OTROS: __________________________________________________________________________

ANTECEDENTES PATOLOGICOS
ENF. CORAZON HIPERTENSION HIPOTENSION ASMA BRONQUITIS
HIPERTIROIDISMO HIPOTIROIDISMO DIABETES ESCLEROSIS CANCER
MULTIPLE
ARTRITIS ARTROSIS DEPRESION TUBERCULOSIS EMBOLIA
REUMATOIDES
ANEURISMA EPILEPSIA NARCOLEPSIA ENF.CIRCULATORIA
SINDROME
METABOLICO
OTROS: ________________________________________________________________________________

ANTECEDENTES QUIRURGICOS: _____________________________________________________________

ANTECEDENTES PSICOLOGICOS: _____________________________________________________________

ANTECEDENTES HOSPITALARIOS: ____________________________________________________________

ANTECEDENTES TOXICO-ALERGICOS: _________________________________________________________

ANTECEDENTES NUTRICIONALES: ____________________________________________________________

ANTECEDENTES TRAUMATOLOGICOS: ________________________________________________________

MOTIVO DE CONSULTA:
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DIAGNOSTICO:
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TRATAMIENTO TERAPEUTICO:
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NUMERO DE SESION: NUMERO DE EXPEDIENTE: