CLÌNICA DE LOS PORTONES

Fecha: __________ Nº:__________

Nombre y Apellido:_______________________________________________

Teléfono : _________________________

Fecha de Nac. :_______________

Historia Clìnica

M.C.:_______________________________________________________________

E.A.:________________________________________________________________
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A.E.A:______________________________________________________________
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A.P.P.:
Hipertensiòn Arterial:__________________ Afecciones Cardìacas:______________
Asma: ____________________ Alergias:__________________________________
Diabetes Mellitus: _________
Intervenciones Quirùrgicas:______________________________________________
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Fàrmacos:____________________________________________________________
Tabaquismo:________________________

A.F.:________________________________________________________________
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Exàmen Fìsico:

Talla:_________ Peso:_______ IMC:_________

SNC.:_______________________________________________________________
P y M.:______________________________________________________________
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P.P:_________________________________________________________________
C.V.: _______________________________________________________________
P.A.:________________________________________________________________

DIAGNÔSTICO:_________________________________________

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TRATAMIENTO PROPUESTO:

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