Formato De Historia Clinica

  • October 2019
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FORMATO DE HISTORIA CLINICA APELLIDOS Y NOMBRES: .................................................................................................................. LUGAR Y FECHA DE NACIMIENTO: .................................................................................................. ESTADO CIVIL: .................................................................................................................................... ANTECEDENTES FAMILIARES Y PERSONALES (Relacionados con estado de salud y enfermedades) ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... .............................................................................................................................................................. ............................................................................................................................................................... EXAMEN MEDICO ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... .............................................................................................................................................................. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... .............................................................................................................................................................. ............................................................................................................................................................... EXAMENES AUXILIARES Adjuntar análisis de sangre (Numeración y fórmula sanguínea; hemoglobina, hematocrito, recuento de plaquetas, reticulocitos; grupo sanguíneo y Rh) Otros exámenes auxiliares se realizarán solo si el médico que examina al solicitante lo considera necesario para descartar o confirmar sospecha diagnóstica. ANTECEDENTES OCUPACIONALES Indicar si anteriormente ha trabajado sometido a otros riesgos diferentes a radiaciones ioinizantes, p.ej. sustancias tóxicas, carcinógenas, etc. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... .............................................................................................................................................................. ............................................................................................................................................................... NOMBRE Y FIRMA DEL MEDICO: ....................................................................... No. DE COLEGIATURA: ............................. (Espacio reservado para la Autoridad Nacional – No llenar) DICTAMEN Y OBSERVACIONES ............................................................................................................................................................... ............................................................................................................................................................... OTAN/HC

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