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1. DATOS PERSONALES
Nombre: _______________________________________ D.I.: __________________
Programa: ______________________________________________ Semestre______
Lugar y fecha de nacimiento: ______________________________Edad: __________
Direccin de los padres:_____________________________Telfono______________
Direccin en Pamplona:______________________________Telfono_____________
Tipo de seguridad social: ____________________________Estado civil: __________
F___M___
2. ANTECEDENTES PERSONALES
Mdicos: _____________________________________________________________
Quirrgicos: ___________________________________________________________
Traumticos: __________________________________________________________
Alrgicos: _____________________________________________________________
Transfusiones: _________________________________________________________
Hospitalarios: __________________________________________________________
Inmunizaciones: ________________________________________________________
Otros: ________________________________________________________________
Ginecobsttricos:
MEN____C____G____P____A____C____FUR_________ FUP_________
Planifica_______________
Citologa: S ___ No___ Ultima fecha: _________________Resultado_____________
3. ANTECEDENTES FAMILIARES (Marque una X en caso positivo)
HTA____ Diabetes____ Cncer____ Epilepsia____ TBC____ Asma____
Enfermedades cardacas____ Enfermedad mental____ Otros___________________
Revisin por sistemas:
Cardio pulmonar: _______________________________________________________
Gastrointestinal: ________________________________________________________
Genitourinario: _________________________________________________________
Osteomuscular: ________________________________________________________
Neuropsiquitrico: ______________________________________________________
Piel y Tejidos blandos: ___________________________________________________
4. DATOS DE CONSUMO DE SUSTANCIAS TXICAS O PRESENCIA DE HBITOS
DE RIESGO
Consumo de Tabaco: SI _____________
NO________________
Consumo de Alcohol: SI _____________
NO________________
Consumo de Substancias Txicas: SI _____________
NO________________
CUALES:
_____________________________________________________________________
____________________________________________________________________
5. MOTIVO DE CONSULTA
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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IPS

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6. ENFERMEDAD ACTUAL
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. EXAMEN FISICO
PA ______ FC ______ FR ______ TEMP ______ PESO _______ TALLA _______
Crneo: ______________________________________________________________
Ojos: ________________________________________________________________
Odos: _______________________________________________________________
Nariz: ________________________________________________________________
Cavidad oral: __________________________________________________________
Cuello: _______________________________________________________________
Trax: _______________________________________________________________
_____________________________________________________________________
Abdomen:_____________________________________________________________
_____________________________________________________________________
Genitourinario: _________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Osteomuscular:________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Neurolgico: __________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Piel:__________________________________________________________________
_____________________________________________________________________
Impresin diagnstica: ___________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Conducta:_____________________________________________________________
_____________________________________________________________________
Paraclnicos: __________________________________________________________
_____________________________________________________________________
Tratamiento: __________________________________________________________
8. OBSERVACIONES
_____________________________________________________________________
_____________________________________________________________________
____________________________
FECHA

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NOMBRE DEL MDICO

__________________________
FIRMA DEL PACIENTE

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FIRMA MEDICO SELLO
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