FECHA: / /
INFORME MEDICO
NOMBRE Y APELLIDO: __________________________________ C.I: _______________________________________________________
DIRECCION: _________________________________________________________________________________________________________
EDAD: ____________________SEXO: ____________________TELF: _________________________________
FECHA DE NACIEMIENTO: _________/______/______________ ENTE/DEPARTAMENTO: _______________________
EMFERMEDAD ACTUAL:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
EXAMEN FISICO:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
DIAGNOSTICO:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
CONDUCTA:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
MEDICO FIRMA, SELLO