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 1. DATOS DE IDENTIFICACIÓN
Fecha de Elaboración: _______________ Historia N° ___________ Modalidad:_________________ Sede:__________
Nombres y Apellidos: __________________________________________________________Escolaridad: __________
Lugar y Fecha de Nacimiento: _______________________________________________________________________
Edad: ________________Ocupación:_________________________________________________________________
Documento de Identidad: RC______ T.I.______ C.C. ______ Número: _______________________________________
Afiliación a Salud: SISBEN_______ E.P.S._______ NO TIENE: _______ CUÁL: _______________________________
Dirección: __________________________________________ Teléfonos: ____________________________________Barrio: ____________________________ Estrato: __________ Localidad: ___________________________________
Acudiente: ________________________________Parentesco: _________________________ Tel: _______________
2. DATOS DE INGRESO
Fecha de Ingreso____________________________
Motivo de Ingreso: ________________________________________________________________________________Descripción Motivo de Ingreso : _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


3. HALLAZGOS FAMILIARES
4.1. FAMILIOGRAMA























3.2. Antecedentes y Estructura Familiar:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3.3. Relaciones Intrafamiliares:
Marital (Papá – Mamá – Red Vincular):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Parental (Materno Filial y Paterno Filial): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Fraternal (Hermanos):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Otro (Familia extensa- Compañera o Hijos):...