Historia Clinica

Historia Clínica

FECHA DE ELABORACION: _____________________________

1.-FICHA DE IDENTIFICACIÓN

NOMBRE ___________________________________________________________________________________

APELLIDO PATERNO APELLIDO MATERNO NOMBRE(S)

EDAD: _______ SEXO: __________ NACIONALIDAD: _________________________

FECHA DE NACIMIENTO: _______________________________________________

MES DÍA AÑO

LUGAR DE NACIMIENTO: ______________________________

EDO. CIVIL: _______________ ESCOLARIDAD: _____________________________________

OCUPACIÓN: ________________________________ RELIGIÓN: ________________________________

DOMICILIO: ___________________________________________________________________________________

CALLE Nº INTERIOR Nº EXTERIOR COLONIA

________________________________________________________________________

CODIGO POSTAL DELEGACION TELEFONO

2.- ANTECEDENTES PATOLOGIACOS

DIABETES:__________________________________________________________________________________________________________________________________________________________________________________

ONCOLOGICOS:______________________________________________________________________________________________________________________________________________________________________________

QUIRURJICOS:_______________________________________________________________________________________________________________________________________________________________________________

CARDIOPATIAS:______________________________________________________________________________________________________________________________________________________________________________

HIPERTENSION ARTERIAL: ____________________________________________________________________

____________________________________________________________________________________________

INFECCIONES RESPIRATORIAS: ________________________________________________________________

OBESIDAD:__________________________________________________________________________________________________________________________________________________________________________________

ALERGIAS: ___________________________________________________________________________________

TRANFUSIONES: ______________________________________________________________________________

OTROS:_____________________________________________________________________________________________________________________________________________________________________________________

3.- ANTECEDENTES HEREDO FAMILIARES:

A) RAMA PATERNA:

ABUELO:_______________________________________________________________________________________________________________________________________________________________________________________

ABUELA:________________________________________________________________________________________________________________________________________________________________________________________

PADRE:_________________________________________________________________________________________________________________________________________________________________________________________

TÍOS PATERNOS: ________________________________________________________________________________ ________________________________________________________________________________________________

B) RAMA MATERNA:

ABUELO:_______________________________________________________________________________________________________________________________________________________________________________________

ABUELA:________________________________________________________________________________________________________________________________________________________________________________________

MADRE:_________________________________________________________________________________________________________________________________________________________________________________________

TÍOS MATERNOS: ________________________________________________________________________________ ________________________________________________________________________________________________

C) HERMANOS(AS):_________________________________________________________________

______________________________________________________________________________________________

D) ESPOSO

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