Historial Clínico Fecha :_____________________

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Edad : __________________________________________________________________

Sexo :____________________________________________________________________

Fecha de nacimiento : _______________________________________________________

Escolaridad : ______________________________________________________________

Estado Civil : ______________________________________________________________

Religión : _____________________________________________________________

Estatura : __________________________________________________________________

Motivo de consulta :
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Descripción :
Antecedentes familiares

Padres

Nombre: __________________________________________________________

Edad:__________

Ocupación : _________________________________________________________

Nombre :_____________________________________________________________

Edad:______________________________________________________________

Ocupación : ________________________________________________________________

Info extra
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Relación con miembros de la familia

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Área Medica

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Antecedentes de enfermedades familiares

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Antecedentes del desarrollo

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Área Escolar

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Area Social

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Area afectiva

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