Nombre:

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Edad: __________________________
Fecha de nacimiento:
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Estado Civil: __________________________
Sexo:
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Instruccin: __________________________
Ocupacin:
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Lugar de Nacimiento: __________________________
Residencia habitual: ____________________________________________________
Residencias
Ocasionales:
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Telfono: __________________________
Motivo de consulta:
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Enfermedad Actual:
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AP
APP:_____________________________________________________________________
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APQ:____________________________________________________________________
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APT:_____________________________________________________________________
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Medicamentos:__________________________________________________________
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Alergia:_________________________________________________________________
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AGO
AM Menarquia: ____________ CICLOS: ____________ DURACION:
_____________ VOLUMEN___________ COAGULOS_________
DISMENORREA_______ FUM: __________________
Menopausia _____________ TRH________________________
AO
G: ________ A: _________P: _________ C: _________
AG
EG:______________________________________________________________________
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ETS:_____________________________________________________________________
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MAM__________________________
APE
H P Tabaco_______________________ Alcohol _______________________
drogas______________________
HNP Dieta: _________________________________
Ejercicio_________________________________________ HDef:
_______________________ HM: _______________________ Sueo:
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APF_____________________________________________________________________
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RAS_____________________________________________________________________
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DSE vivienda ___________________________________pisos
_______dormitorios________
Serv. basicos_____________ mascotas_______________________
Fam

EF: Peso: ________Talla: ________ IMC: ________ TA: ________P: _____ T:

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Manejo:__________________________________________________________________
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