DATOS DE IDENTIFICACION

APELLIDOS:____________________________ NOMBRES:__________________________________________

EDAD: _______ SEXO:______________ C.I.:__________________ ESTADO CIVIL:_______________________

FECHA NACIMIENTO:____________________ LUGAR NACIMIENTO:_______________________________

RELIGION:_________________OCUPACION:_______________________TELEFONO:___________________

DIRECCION:____________________________________GRUPO SANGUINEO:_____ FACTOR:____________

FECHA DE INGRESO:_______________ HORA:____________________LUGAR:________________________

MOTIVO DE CONSULTA: ________________________________________________________________

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ENFERMEDAD ACTUAL: __________________________________________________________________

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ANTECEDENTES PERSONALES

PATOLOGICOS: _____________________________________________________________________________
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QUIRURGICOS:_____________________________________________________________________________
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TRAUMATICOS:_____________________________________________________________________________
ALERGICOS:________________________________________________________________________________
OBSTETRICOS: Menarquia:_________________ Inicio de actividad sexual:_____________________________
Ultima regla:___________________________ Gestas:________Paras:_________ Cesarea:______Abortos:_________
FAMILIAR:__________________________________________________________________________________
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MEDICAMENTOS QUE CONSUME:____________________________________________________________
HABITOS PSICOBIOLOGICOS
Tabaquismo:__________________________________________________________________________________
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Alcoholismo:_________________________________________________________________________________
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Raza:_______________________________________________________________________________________
Hábitos dieticos:______________________________________________________________________________
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REVISION POR SISTEMAS:
Síntomas generales: ____________________________________________________________________________
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Piel y faneras:_________________________________________________________________________________
Ojos. Oídos. Nariz. Boca:______________________________________________________________________
Sistema Cardiovascular__________________________________________________________________________
Sistema Respiratorio____________________________________________________________________________
Mamas______________________________________________________________________________________
Gastro-intestinal_______________________________________________________________________________
Genitourinario________________________________________________________________________________
Venéreas____________________________________________________________________________________
Endocrino___________________________________________________________________________________
Extremidades y locomotor:_______________________________________________________________________
Dolor articular _______________________________________________________________________________
Sistema Nervioso______________________________________________________________________________
EXAMEN FISICO:____________________________________________________________________________
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SIGNOS VITALES: T.A_________________________ F.C__________________F.R______________________
PESO_________________ TALLA_____________________TEMPERATURA__________________________
SISTEMA MUSCULOESQUELETICO
Piel y tejido subcutáneo:_________________________________________________________________________
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Trofismo:____________________________________________________________________________
Dolor:_____________________________________________________________________________________
Tumefaccion:________________________________________________________________________________
Deformidad:_________________________________________________________________________________
ARTICULACIONES Y E. PERIARTICULARES