Historia Clinica

IMSS
Servicio Ginecobstetricia
Diseo: Luis Humberto Cruz Contreras
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Ficha de identificacin
Nombre: ________________________________________________________________________
Afiliacin: ________________________________________________________________________
Edad: ________ aos
Sexo: Femenino
Estado civil: ________________________________________________________________________
Ocupacin: ________________________________________________________________________
Origen: ________________________________________________________________________
Reside: ________________________________________________________________________
Religin ________________________________________________________________________
Interrogatorio: ________________________________________________________________________
Responsable: ________________________________________________________________________
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 _____________________________________