SERVICIOS DE SALUD DE OAXACA

DIRECCION DE ADMINISTRACION

ANALISIS CLINICOS
NOMBRE:
EDAD:__________
ESCOLARIDAD:

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SEXO :_________ EDO. CIVIL:___________ OCUPACIN:_______________________________
____________________________________ RADICA:__________________________________________

GENERAL DE
ORINA:

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QUMICA
SANGUNEA:

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CATASTRO
TORXICO:

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ANTECEDENTES
HEREDITARIOS Y
FAMILIARES

INTERROGATORIO
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ANTECEDENTES
PERSONALES NO
PATOLGICOS Y
HABITOS

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ANTECEDENTES
PERSONALES
PATOLGICOS Y
TRAUMATICOS

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PADECIMIENTO
ACTUAL

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DIGESTIVO Y
ANEXOS:

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INTERROGATORIO POR APARATOS

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RESPIRATORIO:

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CARDIO
VASCULAR:

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UNITARIO:

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GENITAL:

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ENDOCRINO:

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ORGANO DE LOS
SENTIDOS:

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NEUROS
PSQUICOS:

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SNTOMAS
GENERALES:

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TERAPEUTICA
EMPLEADA:

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TRATAMIENTO
MEDICOS
RECIBIDOS:

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EXTRA O INTRAHOSPITALARIOS

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DECLARACIONES DEL SOLICITANTE

CERTIFICO QUE LO ANTERIOR ES EXACTO Y VERIFICO SIN OMITIR OTROS TRANSTORNOS FUNCIONALES ,
RELEVO AL MEDICO EXAMINADOR DEL SECRETO PROFESIONAL PARA USOS CONVENIENTES DE LA SECRETARIA

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FIRMA
EXPLORACION FISICA
ESTATURA:________ PESO:_________ PULSO: ________________ T.A.:______
NMERO DE RESPIRACIONES:______________________________ TEMPERATURA:_______________________
INSPECCION
GENERAL:

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CRANEO Y CARA:

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CUELLO:

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TORAX Y
GLANDULAS
MAMARIAS:

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EXTREMIDADES:

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CONCLUSION
DIAGNOSTICA:

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LUGAR Y FECHA

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NOMBRE Y FIRMA DEL MEDICO

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SELLO

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