Professional Documents
Culture Documents
I. DATOS GENERALES
N de expediente: ___________________________
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Entrevistador:
Nombre: ________________________________________________________________
Ocupacin: ______________________________________________________________
Trabajo: __________________________
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Arrendada
Allegado
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VI. REMISIN
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Cuntas? ______________________________________________________________
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Ha recibido tratamientos? _________________________________________________
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Obligado? ________________________________________
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IX. HISTORIA PRENATAL
Cules? ________________________________________________________________
Pre-maturez
A termino Rpido
Post-madurez Normal
prolongado
Va del parto
Vaginal
cesrea
Cules? ________________________________________________________________
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XI. HISTORIA DE SALUD
Alergias: ________________________________________________________________
Hospitalizaciones: _________________________________________________________
Cirugas: ________________________________________________________________
Fracturas: _______________________________________________________________
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Medicamentos: ___________________________________________________________
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Intoxicaciones: ___________________________________________________________
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Tendencias a accidentes
Ha sido vacunado
Golpes en la cabeza
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Observaciones: ___________________________________________________________
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Madre: __________________________________________________________________
De qu muri? __________________________________________________________
Padre: __________________________________________________________________
De qu muri? __________________________________________________________
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Otros: __________________________________________________________________
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XIV. CONCLUSIONES/SUGERENCIAS
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