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Historia Clinica

IMSS
Servicio Ginecobstetricia
Diseo: Luis Humberto Cruz Contreras

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Ficha de identificacin
Nombre:

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Afiliacin:

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Edad:
Sexo:

________ aos
Femenino

Estado civil:

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Ocupacin:

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Origen:

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Reside:

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Religin

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Interrogatorio: ________________________________________________________________________
Responsable:

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Elaboracin:

______ / ____________/ ________

Escolaridad:

________________________________________________________________________

Antecedentes Heredo Familiares


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Antecedentes Personales NO patolgicos


Habitacin: ___________________________________________________________________________________________________
Alimentacin: __________________________________________________________________________________________________
Actividad / Sedentarismo: ________________________________________________________________________________________
Tabaquismo / alcoholismo / Toxicomanas: _______________________________________________________________________
Inmunizaciones: _______________________________________________________________________________________________
Hemotipo: ___________________________________________________________________________________________________

Antecedentes Personales Patolgicos


Alergias: ___________________________________________________________________________________________________
Patologas: _________________________________________________________________________________________________
Quirrgicos: ___________________________________________________________________________________________________

Transfusionales: _____________________________________________________________________________________________

Antecedentes Ginecoobsttricos
Menarca: ___________ Menstruacin : ____________________ IVSA: _________________ Mtodo Ant.___________
tiempo de uso ____________ FURN: ___/ ________/ _____ FPP ___/_______/_____ Gestas _____ Para ______ Cesreas
____________Abortos ________, No parejas sexuales: __________, Mtodo ant. que desea ______________, Menopausia
____________________ ltima Citologa vaginal ______________________, Autoexploracin mamara
______________________, Mamografa ______________________

Padecimiento Actual
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Sntomas Generales

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Interrogatorio por Aparatos y sistemas


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Exploracin Fsica
Signos Vitales
TA

_____/ ______, FC _______, FR __________ Temp _________ C

Exploracin general
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Cabeza
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Cuello
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Trax
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Abdomen
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Extremidades
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Genitales
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Laboratoriales y estudios de imagen


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Impresin Diagnstica:
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Mip _____________________________________

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