Historia ClnicaDatos de AfiliacinNombre:
_______________________________Edad: ____________Sexo: M/ FEstado
Civil: _____________Ocupacin: ______________Lugar de Residencia:
____________________Lugar de Procedencia: ___________________Fecha
de Ingreso: consciente/inconscienteEmergencias/consulta externa
Motivo de
Ingreso:____________________________________________________________________________________________________________________________________________________Evolucin
de la Enfermedad:Desde cundo le duele? _____________________Antes
se encontraba bien? ___________________Cmo le comenz?
_________________________A_______________L_______________I________________C_______________I________________A_______________EmuntoriosFiebrePrdida
de Peso Apetito Orina Heces Vmito
Antecedentes Patolgicos
Familiares______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Antecedentes
Patolgicos PersonalesTipo de Sangre ___Enfermedad: SI/NO
__________________________________________________________________________________________________________________________________________________________Medicamentos:
__________________________________________________________________________________________________________________________________________________________Tratamiento:
__________________________________________________________________________________________________________________________________________________________Accidentes:
SI/NO__________________________________________________________________________________________________________________________________________________________Hospitalizacin
Previa: SI
/NO__________________________________________________________________________________________________________________________________________________________Alergias:
SI /NO
__________________________________________________________________________________________________________________________________________________________Hbitos
y Encuesta SocialDrogas: SI/ NO ________________________Alcohol:
SI/ NO ________________________Tabaco: SI/ NO
________________________
