Ficha de Identificacin

Nombre
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Sexo
Raza _____________Nacionalidad ________________Civil_____________
Ocupacin __________________________Lugar de Origen _____________________________
Lugar de residencia__________________Domicilio_____________________________________
Persona responsable____________________________________Religin__________________
Fecha de ingreso____________________
Motivo de consulta
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Historia de la enfermedad actual
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Antecedentes
ANTECEDENTES PERSONALES PATOLOGICOS
Antecedentes Mrbidos:
Enfermedades de la infancia: _________________________________________________________________
Enfermedades psiquitricas: _________________________________________________________________
Enfermedades no quirrgicas: _________________________________________________________________
Enfermedades quirrgicas: ___________________________________________________________________
Accidentes: _______________________________________________________________________________
Traumatismos: _____________________________________________________________________________
Fracturas: _________________________________________________________________________________
Transfusiones de sangre: ____________________________________________________________________
Alergias: __________________________________________________________________________________
Incapacidades: _____________________________________________________________________________

Antecedentes Ginecoobsttricos.
Menarqua_______________ Desarrollo Sexual________________________________________
Ritmo Menstrual (f/d/c) ________________FUM_______________Vida sexual _______________
FPP_____________ FUP________________Mat _______________ Menp._________________
Clim_______________________Partos__________Abortos__________Cesreas____________
Mtodo Anticonceptivo____________________________________________________________
Citologa Vaginal________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLOGICOS

Hbitos personales
Bao ___________________ Defecacin __________________ Lav. dientes________________
Habitacin (ctos, piso, techo, ven, hab, servicios) ______________________________________
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Tabaquismo (cig/da/aos) _________________ Alcoholismo (beb/frec) ____________________
Caf (taza/da)________________Toxicomanas (esp/da/aos) __________________________
Alimentacin (f/ tipo) ____________________Res ______Pollo ______ Fruta_____ Cerdo______
Deportes (act. Fsica/f) ____________________ Escolaridad_____________________________
Trabajo/Desc ___________________________________________________________________
Medicamentos:
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Hipersensibilidad / alergias:
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Antecedentes sociales y personales:
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Antecedentes Heredo Familiares:
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Inmunizaciones
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Revisin por sistemas

Aparato digestivo
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Aparato cardiovascular
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Aparato respiratorio
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Aparato Urinario
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Aparato genital
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Aparato hematolgico
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Sistema endocrino
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Sistema osteomuscular
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Sistema nervioso
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Sistema sensorial
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Psicosomtico
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Examen fsico
1. FC: __________________________________________________________
2. TA: __________________________________________________________
3. FR: __________________________________________________________
4. Temperatura: __________________________________________________
5. Peso actual: ___________________________________________________
6. Peso anterior: __________________________________________________
7. Peso ideal: ____________________________________________________
Exploracin general
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Exploracin regional (inspeccin, palpacin, percusin, auscultacin, comb.)
Cabeza
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Cuello
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Trax
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Abdomen
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Genitales
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Extremidades
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Neurolgico
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Diagnostico
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